Active Imagination in Theory, Practice

and Training: The Special Legacy of C.

G. Jung 1st Edition Tozzi
Visit to download the full and correct content document:
https://textbookfull.com/product/active-imagination-in-theory-practice-and-training-the-
special-legacy-of-c-g-jung-1st-edition-tozzi/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

The Quotable Jung C. G. Jung

https://textbookfull.com/product/the-quotable-jung-c-g-jung/

Biota Grow 2C gather 2C cook Loucas

https://textbookfull.com/product/biota-grow-2c-gather-2c-cook-
loucas/

The International Handbook of Shipping Finance: Theory

and Practice 1st Edition Manolis G. Kavussanos

https://textbookfull.com/product/the-international-handbook-of-
shipping-finance-theory-and-practice-1st-edition-manolis-g-
kavussanos/

Leadership: Theory and Practice Peter G. Northouse

https://textbookfull.com/product/leadership-theory-and-practice-
peter-g-northouse/
The Maternal Imagination of Film and Film Theory Lauren
Bliss

https://textbookfull.com/product/the-maternal-imagination-of-
film-and-film-theory-lauren-bliss/

Probability and Mathematical Statistics Theory

Applications and Practice in R 1st Edition Mary C.
Meyer

https://textbookfull.com/product/probability-and-mathematical-
statistics-theory-applications-and-practice-in-r-1st-edition-
mary-c-meyer/

Electrician Training Theory Book for Training 1st

Edition Dole

https://textbookfull.com/product/electrician-training-theory-
book-for-training-1st-edition-dole/

Music of the Renaissance Imagination and Reality of a

Cultural Practice Laurenz Lütteken

https://textbookfull.com/product/music-of-the-renaissance-
imagination-and-reality-of-a-cultural-practice-laurenz-lutteken/

An Analysis of C Wright Mills s The Sociological

Imagination 1st Edition Ismael Puga

https://textbookfull.com/product/an-analysis-of-c-wright-mills-s-
the-sociological-imagination-1st-edition-ismael-puga/
“This remarkable and exciting book brings C.G. Jung’s Active Imagination to
the creative, scientific, spiritual, and transdisciplinary needs of the twenty-first
century. Perspicaciously rooted in Jung, the book reinvents the clinical and provides
essential steppingstones for those taking this practice into art, philosophy and the
synchronistic sciences. With this collection, Chiara Tozzi establishes herself as an
important voice in analytical psychology and its multiple capacities to energize
knowing and being.”
Susan Rowland

“This book offers a series of articles covering a wide scope with the aim of
restoring Active Imagination to its rightful place as a significant method to access
the unconscious and meaning in Jungian analysis. Active Imagination is a method
developed by C.G. Jung which allowed him to access and delve into the images of
his inner world and of the unconscious in order to more clearly understand their
meaning and significance following the painful separation from Freud in 1913.
The images and dialogues that emerged were recorded in the Red Book, which was
kept private till its publication in 2019. The novelty of this method and the unusual
images that emerged initially created concern in those around Jung and led some to
question whether he was not falling into a state of psychosis. In fact, Jung was later
very clear that it was precisely the use of Active Imagination and of the powerful
images and dialogues that emerged as a result that enlightened him and led to a more
profound understanding of the unconscious and of its archetypal contents. One of
the legacies of the history of these early years is that there remains a lingering
skepticism or mistrust with regard to the use and validity of Active Imagination.
As a result, other than in training programs in Zurich, Active Imagination is often
not given much attention. The editor of this book Chiara Tozzi sets out to address
this lacuna and to restore Active Imagination to its rightful place as an invaluable
avenue to access a living experience of psyche and of the unconscious in a personal
manner. She manages this by bringing to the table, contributions from esteemed
Jungian analysts who descrive their use of Active Imagination in clincial practice,
which can include dialogues with dream figures, painting, meditation, body
movement and dance. In addition, she has included voices from the world of the
arts by inviting a director film/critic, a script writer, a professional dancer, a painter,
an author, and a musician to reveal, from their unique and personal perspective, the
central role that Active Imagination played in giving form to their creativity and of
this method as a way of accessing the ephemeral from which meaning can emerge.
The result is a wide-ranging collage of personal testimonies that attest to the
usefulness of Active Imagination as a way to access the creative and the imaginal,
in clinical practice, in ther arts and in our daily lives as an avenue to find meaning.
This book will appeal not only to analysts, therpaists and artists but to everyone
interested in their inner world and in creative expression. I highly recommend this
book and am confident it will nourish many in their search for access to creativity
and meaning in their lives.”
Tom Kelly
“The strength of this book lies in its rich tapestry of voices. It is impressive to learn
about the applicability of Active Imagination in scientific, artistic, and cultural
fields. The editor has masterfully gathered together an exceptional collaboration
of authors that offers a multifaceted exploration of Active Imagination, providing
readers with a treasure trove of insights and perspectives. Across the two volumes
of this book, theory, practice, and research are assembled in a very creative
way that includes research, methodology, theory and practice. Readers will find
references to personal experiences and practical examples that help us understand
the transformative power of Active Imagination as an indispensable attitude
and tool in all creative processes and encounters with the unconscious. Real-
life applications and personal anecdotes add depth and authenticity to this book.
I am sure that Chiara Tozzi’s two-volume book on Active Imagination: Active
Imagination in Theory, Practice and Training: The Special Legacy of C.G. Jung
(vol 1) and Interdisciplinary Understandings of Active Imagination: The Special
Legacy of C.G. Jung (vol 2) is a signigicant contribution that keeps the spark alive
of one of C.G. Jung’s most important legacies.”
Pilar Amezaga

“Chiara Tozzi presents her research on the essential factor in analytical work that
makes Jungians unique. Active Imagination is engagement with the psyche that
speaks in images from within and from without. In this process one is guided by
the wisdom of the Self that moves the development of the personality towards
increased consciousness and wholeness. Tozzi clarifies that it is a process specific
to the individual rather than a “technique”. It furthers engagement with our fears
and the unknown leading to the Transcendent Function that results in profound
changes in our personality. Conversely though, it is this hard work and frightening
engagement that deter many from its use. This book challenges us with a reminder
of C.G. Jung’s deeply effective creative path to healing.”
Nancy Swift Furlotti
Active Imagination in Theory,
Practice and Training

Based on extensive research and developed with the support of the IAAP, this
fascinating new work presents the precious value of the special legacy of C.G.
Jung, which he himself defined as Active Imagination, through a collection of
unpublished contributions by some of the brightest Jungian analysts and renowned
representatives from the worlds of Art, Culture, Physics and Neurosciences.
In addition to presenting the genesis, development and results of Chiara Tozzi’s
research on Active Imagination, this volume on Theory, Practice and Training will
also include the fundamental theoretical aspects of this technique. The book explores
Active Imagination in relation to fundamental contents of Analytical Psychology,
such as Individuation, Transformation and comparison with the Shadow, the
four psychological functions, C.G. Jung’s Red Book, and more. Moreover, the
connections between Active Imagination and Sandplay will also be explored, as
well as the possibilities of applying the technique with adolescent patients, how
it’s considered and proposed in Jungian Training, and some innovative clinical
methodologies of Active Imagination.
Spanning two volumes, which are also accessible as standalone books, this
essential collection will be of great interest to Jungian analysts, psychologists,
psychoanalysts, or anyone interested in discovering more about the fascinating
psychotherapeutic practice of Active Imagination and its interdisciplinary uses.

Chiara Tozzi is a Psychologist and Psychotherapist. She is a Training Analyst

and Supervisor of Associazione Italiana di Psicologia Analitica (AIPA) and of
the International Association for Analytical Psychology (IAAP). She is also a
Writer, Screenwriter, and Screenwriting Professor. She is Artistic Director of the
‘Mercurius Prize’, based in Zurich.
Active Imagination in Theory,
Practice and Training

The Special Legacy of C.G. Jung

Edited by Chiara Tozzi

Designed cover image: Getty Images
First published 2024
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2024 selection and editorial matter, Chiara Tozzi; individual
chapters, the contributors
The right of Chiara Tozzi to be identified as the author of the
editorial material, and of the authors for their individual chapters,
has been asserted in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted
or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from the
publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British
Library
ISBN: 978-1-032-53301-8 (hbk)
ISBN: 978-1-032-53300-1 (pbk)
ISBN: 978-1-003-41136-9 (ebk)
DOI: 10.4324/9781003411369
Typeset in Times New Roman
by Apex CoVantage, LLC
To my masters,
to my patients,
to my students.
Contents

About the Editor xi

List of Contributors xii

1 Active Imagination: The Special Legacy of C.G. Jung 1

ChIARA TOZZI

2 Active Imagination, Agent of Transformation in the

Individuation Process 19
MuRRAy STeIN

3 Active Imagination and the Process of Individuation 34

FeDeRICO De LuCA COMANDINI – TRANSLATeD By ROBeRT
MeRCuRIO

4 Is Active Imagination the Sleeping Beauty of

Analytical Psychology? 48
GAeTANA BONASeRA – TRANSLATeD By ALeSSIA MARZANO

5 Sandplay Therapy and Active Imagination 60

evA PATTIS ZOJA

6 Imaginative Movement Therapy: A Neo-Jungian Approach

to Active Imagination 65
LANeR CASSAR

7 The Magic Labyrinth: Imagine a Game to Be Played

with Images 76
vALeRIO COLANGeLI
x Contents

8 yesterday, Today and Tomorrow: Active Imagination,

Analytical Training and Clinical Practice 97
MARTA TIBALDI

9 Symbols of the Soul: From The Red Book to Active

Imagination in Movement 112
ANTONeLLA ADORISIO

Index 130
About the Editor

Chiara Tozzi is a Psychologist and Psychotherapist. She is a Training Analyst

and Supervisor of Associazione Italiana di Psicologia Analitica (AIPA) and of
the International Association for Analytical Psychology (IAAP). She is also a
writer, screenwriter and screenwriting professor. She lectures internationally,
and is a visiting Professor to different IAAP Developing Groups. She is author
of an International Research on Active Imagination supported by the IAAP, to
be published by Routledge. She is Artistic Director of the international “Mer-
curius Prize for Films of Particular Psychological Significance and Sensitivity
to human Rights”, based in Zurich. She is former editor of Studi Junghiani, the
journal of the AIPA.
Contributors

Antonella Adorisio is a Training and Supervising Jungian Analyst with CIPA and
IAAP. Past Director of Programming and Training at CIPA – Institute of Rome.
Past Member of CIPA National executive Board, she was President of the
17th CIPA National Congress in 2016. Antonella is a Registered Psychologist,
Psychotherapist, Dance Movement Psychotherapist and Art Psychotherapist. She
has been internationally teaching Active Imagination for many years. As a teacher
of Authentic Movement, she studied with Janet Adler and Joan Chodorow. She
leads international workshops on Authentic Movement and since 2004 she has
been collaborating with Joan Chodorow as co-leader at the Pre-Congress day on
Movement as a form of Active Imagination at the IAAP international congresses
(Barcelona, Cape Town, Montreal, Copenhagen, Tokyo, vienna). She is the au-
thor of numerous papers on Active Imagination, Authentic Movement, Body/
Psyche connections and the Feminine published in Italy, the uK and the uSA.
She has co-edited several books. She works and teaches mainly in Rome. She has
been invited to lecture and teach in Kiew, Bucharest, Malta, Singapore, Zurich
and in several Italian cities. She is still teaching Authentic Movement at ISAP
Zurich as Guest Teacher. She is working with the IAAP Training Router Program
in Romania. She filmed and edited the film-documentary “Mysterium – A Poetic
Prayer-Testimonials on Body/Spirit Coniunctio”, offered in many countries. The
DvD was distributed by Spring Journal Books.
Gaetana Bonasera, PsyD, is a Jungian Analyst, IAAP and AIPA Member. She
graduated in Psychology from Sapienza university of Rome. She obtained su-
pervised systemic-relational psychotherapy training, a Master’s in hypnosis and
ericksonian Psychotherapy, and a master’s in emergency Psychology and Psy-
chotraumatology. PsyD Bonasera has been working as a private psychotherapist
for more than 20 years. Since 2018, she has been a Member of the DuN-Onlus
Association that provides psychological support to migrants and refugees. She
attended the AIPA Training Seminar on Active Imagination by Chiara Tozzi in
2019. She was also a speaker at the conference on Active Imagination by Chiara
Tozzi: “Who Is Afraid of Active Imagination?” (AIPA, Rome 2019) as well as
in the seminar by Chiara Tozzi “From horror to ethical Responsibility” (AIPA,
Milan 2020).
 Contributors xiii

Laner Cassar is a Jungian Analyst (IAAP) from Malta. he is also a registered clini-
cal Psychologist, Psychotherapist and Supervisor working with mental health
services, and currently heads the Psychology Department at the Gozo General
hospital/Steward health Care Malta. he hails from the “essex school of analyti-
cal psychology” of the Centre for Psychoanalytic Studies, university of essex,
uK, where he earned his PhD in Psychoanalytic Studies. he is also an independ-
ent researcher in the history of psychoanalysis, analytical psychology and im-
aginative psychotherapy. Dr Cassar is engaged in various local and international
educational institutions. he has written several publications on his main interest,
namely the use and application of imagination in psychotherapy. his latest book
was published by Routledge in 2020 and is entitled Jung’s Technique of Active
Imagination and Desoille’s Directed Waking Dream Method – Bridging the Di-
vide. he is the President of the Malta Depth Psychological Association, Director
of SITe (Malta) and the International Network for the Study of Waking Dream
Therapy (INSWDT).
Valerio Colangeli, IAAP and AIPA Analyst, is a clinical Psychologist and Psy-
chotherapist. he collaborates with a social cooperative non-profit organisations
as an operator in some residential and semi-residential psychiatric services of
the ASL-RM1, with both adult and adolescent patients. he also has a private
practice. he is the author of publications in Italian and in international journals.
his main fields of research are analytical work in institutions and symbolic play
in adolescence. he attended the AIPA Training Seminar on Active Imagination
by Chiara Tozzi in 2019. he was also a speaker at the conference on Active
Imagination by Chiara Tozzi: “Who Is Afraid of Active Imagination?” (AIPA,
Rome 2019) as well as in the seminar by Chiara Tozzi “From horror to ethical
Responsibility” (AIPA, Milan 2020).
Federico De Luca Comandini is a Jungian IAAP Analyst who graduated from
the C. G. Jung Institute Zurich. he trained under D. Baumann and M. L. von
Franz. he is a Member of the International Association for Analytical Psychol-
ogy (IAAP), International Association of Graduate Analytical Psychologists,
Zurich (AGAP) and Ordinary Member and Teacher at the Associazione Italiana
Psicologia Analitica (AIPA). he holds seminars and participates as a speaker at
conferences in Italy and worldwide. he carries out research on symbolism, in
particular on the psychological processes involved in imagination. he is the au-
thor of many publications, including L’Immaginazione Attiva. Teoria e pratica
nella psicologia di C. G. Jung (2002, curated with R. Mercurio), In dialogo
con l’inconscio (2011) and Quattro saggi sulla proiezione. Riverberi del Sé
nella coscienza (2013), with the contributions of R. Mercurio, D. Ribola and
C. Widmann. he lives and practises in Rome.
Robert Mercurio is a Training Analyst and President of the Association for Re-
search in Analytical Psychology (ARPA). After graduating in philosophy and
then in management, he carried out his post-graduate studies in philosophy and
theology at the Gregorian university in Rome. he then completed the training
xiv Contributors

programme at the C.G. Jung Institute in Zurich where he got his diploma in
Analytical Psychology.
Eva Pattis Zoja is a Jungian Analyst and Sandplay Therapist. She works in private
practice in Milan, Italy. She is the founder of the International Association for
expressive Sandwork (IAeS) and has offered training in Jungian Analysis and
Sandplay Therapy in europe, Asia, Latin America and Africa.
Murray Stein, PhD, is a Training and Supervising Analyst at the International
School of Analytical Psychology Zurich (ISAP-ZuRICh). he was President of
the International Association for Analytical Psychology (IAAP) from 2001 to
2004 and President of ISAP-ZuRICh from 2008 to 2012. he has lectured inter-
nationally and is the editor of Jungian Psychoanalysis and the author of Jung’s
Treatment of Christianity, In MidLife, Jung’s Map of the Soul, Minding the Self,
Outside Inside and All Around, The Bible as Dream and most recently Men Un-
der Construction. he lives in Switzerland and has a private practice in Zurich.
Marta Tibaldi is a Psychologist, Psychotherapist, Jungian Analyst and Training
and Supervising Analyst at IAAP and AIPA. From 2010 to 2019 she was the Li-
aison Person of the IAAP Developing Group in hong Kong (hKIAP) and from
2012 to 2019 an applied visiting Analyst in Taipei, Taiwan. She was an adjunct
Professor of Intercultural Psychology at the university of Siena and a Consult-
ant at the Italian Center of Solidarity “Don Mario Picchi Onlus” in Rome. Since
2008, she has been a teacher at the AIPA’s analytical high School in Rome.
Lecturer in national and international congresses and workshops, and author
of many articles and essays, she has published the books Il mito delle isole fe-
lici nelle relazioni di viaggio del Sette-Ottocento (with G. Mazzoleni, D’Anna,
Messina-Firenze 1975); Oltre il cancro. Trasformare creativamente la malattia
che temiamo di più (Moretti & vitali, Rome 2010); Pratica dell’immaginazione
attiva. Dialogare con l’inconscio e vivere meglio (La Lepre, Rome 2011; en-
larged edition published in Mandarin by PsyGarden Publishing, Taiwan and in
simplified Chinese by Beijing ChenSheng Culture Communication Co. Ltd.);
Transcultural Identities. Jungians in Hong Kong (with T. Chan, M. Chiu, M.
Lee, B. Tam, e.T. Wong, Artemide edizioni, Rome 2016); Jung e la metafora
viva dell’alchimia. Immagini della trasformazione psichica (ed. with S. Massa
Ope and A. Rossi; Moretti & vitali, Bergamo 2020). She is the author of the
blog “C.G. Jung’s Analytical Psychology between Italy and China”, now re-
named “Conoscersi per conoscere”. She also has a website and a video channel
called “Marta Tibaldi. Psicologia analitica in un click”.
Chapter 1

Active Imagination
The Special Legacy of C.G. Jung

Chiara Tozzi

The Pursuit of Active Imagination

The objective of this two-volume book on active imagination can be defined by two
statements by C.G. Jung. I will begin with the first:

The years when I was pursuing my inner images were the most important in
my life – in them everything essential was decided. It all began then; the later
details are only supplements and clarifications of the material that burst forth
from the unconscious, and at first swamped me. It was the prima materia for a
lifetime’s work.
(Jung, 1961, MDR, cap. VI p. 137)

When I read Memories, Dreams, Reflections for the first time in 1978, it was this
very sentence, and the account of C.G. Jung’s courageous confrontation with the
unconscious, that particularly struck me. In the description of that dialogue and
encounter with obscure and dangerous parts of oneself, which could fascinate but
also instill horror, I found echoed the significant contents and images of the fair-
ytales and legends that had captivated me as much as any other kid in childhood,
regardless of the time and space in which that narration had taken place. And it
was exactly from listening to and reading fairytales that a passion for storytelling
was born in me, both as a mode of communication and as a profession, in literature
and film.
When I started my training to become a Jungian analyst at Associazione Italiana
di Psicologia Analitica (AIPA) in 1996, Dr Bianca Garufi, one of the most im-
portant Italian Jungian analysts, explained to me that this way of confronting the
unconscious, first experimented by Jung on himself, was a real form of therapy,
specific to Jungian clinical practice and referred to as active imagination.
Meeting Bianca Garufi resulted in a friendship that was precious to me. I met
her at the making of the feature film Le parole sono altrove1 (Tozzi et al., 2000)
with the AIPA Cinema Group. Bianca Garufi – with whom I had carried out one
of the interviews needed to be admitted to the AIPA-IAAP Training – was the
one who had invited me to join the AIPA Cinema Group because, although I was

DOI: 10.4324/9781003411369-1
2 Chiara Tozzi

then an AIPA trainee and not yet an AIPA-IAAP member, I had been a scriptwriter
and screenplay teacher for over a decade. Bianca Garufi, in addition to being an
AIPA-IAAP training analyst, was a recognized writer and poet: as a writer, she had
published several books, including a novel written in four hands, including one of
the most important Italian writers, Cesare Pavese (Garufi and Pavese, 1959). Here,
I would like to recall one of her qualities as a poet – as I have done elsewhere:
her splendid poem “Non l’Io” (Not the Ego; Garufi, 2002), referring precisely to
the conversation between the Ego and the unconscious that takes place during the
experience of active imagination. I was thus fortunate to have a first illustration
of the complex and special essence of active imagination precisely through that
“double-meaning” language that Bianca Garufi used spontaneously, and of which
Jung speaks about his way of writing (von Franz, 1988): i.e. giving voice to a har-
monious interaction between consciousness and the unconscious. Bianca Garufi,
as an artist, could express herself and write in such a special way because she
naturally possessed that more permeable diaphragm between consciousness and
the unconscious (Jung, 1916/58), which for Jung is typical of creative people; yet,
that more permeable diaphragm can be reached by anyone through the experience
of active imagination, by virtue of the activation of the transcendent function, that
is, that “movement out of the suspension between two opposites, a living birth that
leads to a new level of being, a new situation” (Jung, 1916/58, par. 189).
The specificity of the therapeutic method Jung had identified and experimented
on himself, i.e. active imagination, seemed to me extraordinary and valuable; at
the same time, the fact that, during the six years of AIPA training and afterwards,
I heard very little about it in the Jungian community was disconcerting.
Over time, I learned that this bizarre scotomization of a legacy that appears to
be not only precious, but Jung’s most specific clinical methodology compared with
other psychoanalytical methods developed by famous scholars of the psyche, was
not only taking place in Italy, but throughout the international Jungian community.
Certainly, the publication of The Red Book (Jung, 2009) and its worldwide dis-
semination necessarily led to recognizing that “first matter for a lifetime’s work”
mentioned by Jung in Memories, Dreams, Reflections. But what else was that “first
matter,” so admirably depicted and described in The Red Book, if not precisely the
contents of the unconscious that sprang from Jung’s courageous experience of ac-
tive imagination? And yet, while such contents and illustrations, after the publica-
tion of The Red Book by Sonu Shamdasani, became the object of in-depth study by
the international Jungian community and anyone interested in the psyche, the same
cannot be said for the dissemination of active imagination, which was also at the
origin of those contents and illustrations. Focusing on one of the special qualities of
The Red Book, namely its ability to symbolically illustrate a complex psychologi-
cal journey through written and visual images that were never saturated, I decided
to refer precisely to that double background used by Jung to explain his expository
peculiarity. I therefore made a video, entitled Un doppio fondo,2 in which I tried
to summarize the affinities between the language of film and those of C.G. Jung’s
analytical psychology.
 Active Imagination: The Special Legacy of C.G. Jung 3

Encouraged by the feedback I received from some IAAP colleagues,3 I con-

tinued to explore this connection between languages in light of active imagina-
tion, and followed up the screening of the video (the English version is called En
Route) for the paper “En Route: From Active Imagination to Film Language,”
which I presented in 2013 at the 19th IAAP International Congress in Copenhagen
(Tozzi, 2014).
After becoming a training analyst, in 2014 I was given the Seminar on active
imagination at AIPA, which I have held every year since then (Colangeli, 2022).
My first concern at the time was to try to pass on to AIPA trainees not only the
theoretical aspect of active imagination, but what Jung had truly tried to pass on
to us with his personal experience. In fact, I believe Jung does not reductively and
literally tell us that what he wants to pass on and deliver is a pattern, a technique,
or a method; rather, he leaves us a personal and suffered testimony, experienced
first-hand, on how he symbolically lived the years when he practiced active imagi-
nation. His reluctance to present a “technical” pattern and outline of the practice
of active imagination shows us how important it is to leave more space in the life
of human beings for the individuative and transformative meaning and outcome of
active imagination, as seen in Memories, Dreams, Reflections and in The Red Book.
Actually, I had and still have the impression there is a twofold approach within
the Jungian community to the possibility of learning and teaching active imagina-
tion (Tozzi, 2023):

1 as a mainly mentalized repetition of a technique;

2 as a personalized integration of a different way of being in the world, of a capac-
ity for equal confrontation with the unconscious, related to synchronicity and
fundamental in the process of individuation.

The first and meaningful support to represent the approach I believed is most in line
with the meaning given by Jung of active imagination (that is, the second one) came
to me from Gerhard Adler’s description of active imagination, in Studies in Analyti-
cal Psychology (Adler, 1948). In that essay, Gerhard Adler very efficiently clarifies
the difference between the two approaches, arguing that one cannot speak of a

“technique” of active imagination just as one can hardly speak of a “technique

of dreaming” [. . .] By “active imagination” we understand a definite attitude
towards the contents of the unconscious [. . .] The right attitude may perhaps be
best described as one of “active passivity” [. . .] It is not unlike watching a film
or listening to music [. . .] Only the difference is that in active imagination the
“film” is being unrolled inside.
(Adler, 1948, pp. 56–57)

To me, this brilliant and evocative explanation, based both on logic and on the met-
aphorical use of images, translated into a further image: that of “a different way of
being in the world” (Tozzi, 2017), reachable through the individuative experience
4 Chiara Tozzi

in active imagination. Based on this assumption, I decided to submit a proposal

for the 20th IAAP International Congress to be held in Tokyo, Japan, in 2016.
Before the Congress in Kyoto, a second contribution was fundamental to convince
me that the journey I had embarked on in my research on active imagination truly
made sense. As I have broadly described elsewhere (Tozzi, 2023, op. cit.), in the
summer of 2015 I was at Yale University4 to present “The Experience of Grace: The
Possibility of Transformation in Vladimir Nabokov and Carl Gustav Jung” (Tozzi,
2015). There, I attended Murray Stein’s incredible conference, “Synchronizing
Time and Eternity: A Matter of Practice” (Stein, 2017). On that occasion, Stein’s
presentation was unfolding all my doubts and dilemmas related to my choice to
teach, practice, and experience active imagination as an attitude and not as a tech-
nique. Actually, in his lecture, Stein presented an active imagination done by Pauli
in 1953, stimulated by Jung and M.L. von Franz and defined by Pauli himself as
“The Piano Lesson.” In “The Piano Lesson,” Pauli questioned himself on the same
dilemma I was facing, represented in his active imagination, as follows: “There
were two schools: in the older of the two one understood words but not meaning,
while in the newer one understood meaning but not my words. I could not bring
the two schools together” (Atmanspacher, Primus, and Wertenschlag-Birkhauser,
1995, pp. 317–330). Stein explained the two positions as follows:

At one level, this is a reference to the schools of nuclear physics and analytical
psychology; at another level, it refers to the explanations that science offers and
the meanings that derive from a depth psychological and spiritual orientation.
Here Pauli was stuck.
(Stein, op. cit. p. 50)

As highlighted by Stein, to metaphorically represent this situation:

What he [Pauli, Ed.] came up with was a marvelous image, the piano, which
with its black and white keys resonates with the Chinese yang-yin system. [. . .]
But then it became a matter of learning “to play the piano,” not only of under-
standing the issues intellectually [. . .]. This was the challenge put to him by
Jung and von Franz.
(Stein, op. cit., p. 50)

After sharing Pauli’s touching and meaningful active imagination, Stein added:

Pauli faces this issue head-on in this “active fantasy.” The piano symbolizes a
possible point of meeting. It represents the transcendent function, a synthetic
mind. Of course, the question is: Can he play the piano? Well, he is learning.
[. . .] At any rate, Pauli has given us in the image of the piano a useful metaphor
for the transcendent function, which may assist our efforts to create a sustained
and sustaining link between time and eternity for ourselves and with our patients.
(Stein, op. cit., pp. 55–56)
 Active Imagination: The Special Legacy of C.G. Jung 5

Following this inspiring lecture, when I was back in Rome I decided to write
to Murray Stein, although I did not know him personally. I told him how much
I had appreciated his lecture at Yale and I explained to him that, by presenting
Pauli’s active imagination on “The Piano Lesson,” he had given a symbolic an-
swer to my consideration on the two ways of experiencing and passing on active
imagination. After all, my question on how to explain an attitude of active im-
agination had already been answered in the title of his lecture: it is . . . “A matter
of practice”!
Ever since, all my detailed studies, conferences, and seminars on active imagina-
tion have been focused on trying to pass on to colleagues, patients, and trainees the
meaning of that “different way of being in the world,” given by a true experience
of active imagination, as well as by the fascinating connections between active
imagination and other forms of expression and of human research.
But . . . there is a but!
As I felt the enthusiasm and interest grow within me and received positive feed-
back on active imagination from many IAAP colleagues and trainees, both in Italy
and in other countries I was visiting regularly as IAAP Visiting Professor, the dis-
semination and formation on this special Jungian method was still lacking.
When trainees asked me for a bibliography, I was forced to note there was a
clear lack of publications in the field, especially compared with other topics that
are more followed and analyzed within the Jungian community. I asked myself the
reason for this scotomization, so unequal compared to such unique magnificence
which we possess as Jung’s followers. I came up with a possible answer: that,
in fact, active imagination . . . scares. Nothing weird about that, considering the
complex and delicate journey to undergo to reach a dialogue with the unconscious
in a waking state, as required by active imagination. Yet, although understandable
in patients and trainees, such blind fear is not comprehensible in Jungian analysts
and, actually, seemed to me to be quite concerning. This is how I came up with
the idea of addressing this “troublesome” issue at the 21st IAAP International
Congress to be held in Vienna. I submitted my proposal of this difficult topic and
I am thankful to my IAAP colleagues not only for accepting my presentation, but
for inviting me to present “From Horror to Ethical Responsibility: Carl Gustav
Jung and Stephen King Encounter the Dark Half Within Us, Between Us and in
the World” in a plenary session. I must say that the unexpected and enthusiastic
reaction by colleagues on that occasion was an additional stimulus that pushed me
to go full throttle and even more in-depth: I ventured into a collective research
on active imagination that I could have presented to IAAP colleagues. My video-
interview, “The Lighting of Shadow Images – Interview with Giuseppe Torna-
tore,”5 shot in the projection room of Tornatore’s office in August 2019, in which
Oscar-awarded director Giuseppe Tornatore confronts himself with Jungian active
imagination for the first time, was another important step that pushed me to carry
on with my project.
The final spark came from something else, but I will talk about that at the end
of this chapter.
6 Chiara Tozzi

Support and Cooperation for My International

Research on Active Imagination
This book is therefore the result of my research on active imagination, carried out
with the support of the IAAP.
My proposal was submitted to the IAAP Academic Sub-Committee in 2021, and
was soon after approved and granted a fund.6
In my research project, I asked for, and received, the collaboration of many
IAAP colleague analysts from different countries who were particularly interested
and who specialized in active imagination. I also asked for, and received, contribu-
tions from experts in the worlds of Neurosciences, Physics, Art, and Culture. The
Research Unit RISORSA – Social Research, Organization and Risk in Health – of
DiSSE – Department of Social and Economic Sciences – of the Sapienza Univer-
sity of Rome, Italy also provided their collaboration.
Additional support was also given by Shannon Marie Clay, freelance inter-
preter and translator who supported me in editing the book and translating some
of the chapters. I am really thankful to Shannon, the backbone of this entire
journey.
Following, the final list of participants:

IAAP Analysts
1 Tozzi, Chiara, AIPA-IAAP, Italy
2 Adorisio, Antonella, CIPA- IAAP, Italy
3 Bonasera, Gaetana, AIPA-IAAP, Italy
4 Cassar, Laner, Malta Jung Developing Group-IAAP, Malta
5 Colangeli, Valerio, AIPA-IAAP, Italy
6 De Luca Comandini, Federico, AIPA-IAAP, Italy
7 Deligiannis, Ana, SUAPA-IAAP, Argentina
8 Fleischer, Karin, SUAPA, IAAP, Argentina
9 Méndez, Margarita, SVAJ-IAAP, Venezuela
10 Mercurio, Robert, ARPA, Italy7
11 Nieddu, Gianfranca, AIPA-IAAP, Italy
12 Pattis Zoja, Eva, CIPA, Italy
13 Renn, Regina, DGAP- IAAP, Germany8
14 Stein, Murray, AGAP-IAAP, Switzerland
15 Tibaldi, Marta, AIPA-IAAP, Italy

Representatives from the Worlds of Art, Culture,

Neurosciences, and Physics, and Sapienza
University of Rome, Italy
16 Aiolli, Giacomo, musician, Italy
17 Clay, Shannon Marie, linguist, Italy
 Active Imagination: The Special Legacy of C.G. Jung 7

18 Cogliati Dezza, Irene, research fellow in the Affective Brain Lab at University
College London and Massachusetts Institute of Technology
19 Contarello, Umberto, scriptwriter, Italy
20 Padroni, Luca, painter, Italy
21 Piperno, Elsa, dancer, choreographer and dance teacher, Italy
22 Puddu, Emiliano, physics professor, Italy
23 Sesti, Mario, critic-journalist, Film Festival Director and Documentary Direc-
tor, Italy
24 Voltolini, Dario, writer, Italy
25 Research Unit RISORSA – Social Research, Organization and Risk in Health –
of DiSSE – Department of Social and Economic Sciences – of the Sapienza
University of Rome, Italy9

Research Characteristics and Methodology

First Phase
My research on active imagination was a “qualitative” research which therefore
required the necessary tools to translate qualitative data into quantitative data for
the needed analysis and comparisons.
To this end, two “structured” questionnaires with predefined answers were pro-
vided for a numerical translation. One questionnaire was sent to IAAP members,
trainees, and routers to verify their knowledge, appreciation, and clinical practice
of active imagination. A second questionnaire was sent to the people in charge of
IAAP training (IAAP training analysts) and covered the relevance given to active
imagination during IAAP trainings.
The questionnaires were submitted through an online platform and, based on the
answers received, were processed in progress by the Research Unit RISORSA of
Sapienza University of Rome, Italy.
A report on the answers collected was sent to me, and I then forwarded the re-
sults to my IAAP colleagues who contributed to this research.
The results of the first phase were aimed at providing useful material for a per-
sonal processing and/or a collective discussion among IAAP analysts taking part in
this research. The material was made available for analysts to use in their personal
contributions to the research.

Second Phase
During the second phase, the IAAP analysts working on this research were free
to choose whether they wanted to work by themselves on a topic related to active
imagination, or to exchange opinions with myself and/or the other participants.
At the same time, during the second phase, additional contributions were pro-
vided by a neuroscientist and a physics professor, as well as contributions and
amplifications from the world of contemporary culture and art.
8 Chiara Tozzi

The results of the questionnaires and the contributions and knowledge provided
by participants could be shared collectively after I sent them out. This was aimed
at favoring a network of connection and exchange among IAAP analysts taking
part in the research, and among the neuroscientist and physics professor and all
representatives from the world of culture and arts who decided to take part in this
specific research development. This exchange could lead to further contributions
aimed at providing detailed empirical studies as well as new and original content
to corroborate the importance given by C.G. Jung to active imagination. Moreover,
it could help to highlight that active imagination is a unique psychotherapeutic
method, different from all the other methods available and practiced in psychoa-
nalysis and psychotherapy.
The results of the research were collected in a structured database. From the
beginning, a possible outcome of such data and all material produced and collected
was to give life to a publication managed by me, as editor of this research.
The quality of the questionnaire was monitored by the Research Unit RISORSA
of Sapienza University of Rome. I then analyzed the results of the questionnaire
and summarized and interpreted them.

Trend of the Research

The research project started in 2021, stemming from the hypothesis that the the-
ory and practice of active imagination, although fundamental and crucial in C.G.
Jung’s analytical psychology, are not well known, studied, and practiced within the
Jungian community, and are very little known to all those who are not part of the
purely psychoanalytical setting.
The first goal of my research was to:

1 Verify the truthfulness of the hypothesis through one questionnaire divided in

two parts, as previously described. I designed and then prepared and managed
the questionnaire with the support of the Research Unit RISORSA, DiSSE,
Department of Social and Economic Sciences of Sapienza University of
Rome, Italy.
The questionnaire was to be sent to all IAAP members, routers, and trainees,
and IAAP training analysts.

Questionnaire Emerging Questions

i How aware are IAAP members of active imagination?
ii Was active imagination considered meaningful and valuable in C.G. Jung’s
clinical practice?
iii How much importance is given by IAAP members to active imagination as a
psychotherapeutic method?
iv Which scientific, artistic, and expressive fields can be linked to active
imagination?
 Active Imagination: The Special Legacy of C.G. Jung 9

v To what level is active imagination used in Jungian psychotherapy?

vi How much research is there on active imagination?
vii Is active imagination properly addressed in IAAP training?
viii How to bridge the possible gap at the level of training, knowledge, and
clinical practice?
2 Analyze and evaluate the results of the questionnaires.
3 Prepare a database based on the scientific evidence of the theoretical knowl-
edge, practice, and training of active imagination by IAAP analysts to support
IAAP dissemination programs about active imagination at the international
level.

Administration, Timing of Data Processing, and Validity

of the Questionnaire
The questionnaire was carried out and processed by the Research Unit RISORSA –
Social Research, Organization and Risk in Health – of DiSSE – Department of
Social and Economic Sciences – of the Sapienza University of Rome, Italy
The survey was carried out from August 27 to October 15, 2021.
The questionnaires were sent by the IAAP Secretariat to 3,564 individuals
among IAAP training analysts and IAAP members, and to 378 individuals among
IAAP routers and trainees, for a total of 3,942 individuals.
Overall, 12.63 percent of the reference population answered the questionnaires.
The level of response was sufficient for an online survey and it could therefore
be considered valid.

Interpretation of the Final Data of the Questionnaire

First consideration: although the questionnaire is valid, I think it is interesting to
think about this: why didn’t 87.37 percent – almost 90 percent! – of IAAP members
respond to the questionnaire?
Only in a few countries was there a high response rate to the questionnaire.
Among these, for IAAP members, routers, and trainees the highest response was
recorded in:

United States 87
China 27
Italy 27
United Kingdom 24

For IAAP training analysts, the highest response was recorded in:

Germany 38
United States 27
Switzerland 17
 Total Respondents by Country
COUNTRY N COUNTRY N
Argentina 4 Italy 27
Australia 2 Japan 3
Austria 4 Latvia and Lithuania 1
Belarus 2 Lithuania 1
Belgium 3 Luxembourg 1
Brazil 23 Malta 3
Bulgaria 3 Mexico 2
Canada 12 Netherland 1
Chile 2 Peru 1
China 27 Poland 2
Colombia 1 Portugal 1
Czech republic 1 Romania 5
Denmark 5 Russia 11
Dominican Republic 2 Serbia 3
Estonia 1 South Africa 5
France 8 South Korea 3
Georgia 11 Spain 4
Germany 9 Switzerland 18
Hong Kong 1 UK 24
Hungary 1 Ukraine 6
India 5 Uruguay 2
International 1 USA 87
Ireland 1 Venezuela 2
Israel 2 Total overall 344

Figure 1 Table of IAAP member, router, and trainee respondents by country.

Total Respondents by Country

COUNTRY N
Argentina 2
Australia 2
Austria 4
Brazil 8
Canada 5
Chile 1
China 3
Czech republic and the Netherlands 1
Denmark 3
Deutschland, schweiz 1
France 4
Germany 38
Israel 10
Italy 13
Italy and Switzerland 1
Japan 1
Russia 3
Serbia 1
South Africa 1
South Korea 1
Spain 2
Switzerland 17
UK 4
Uruguay 1
USA 27
Total overall 154

Figure 2 Table of IAAP training analyst respondents by country.

 Active Imagination: The Special Legacy of C.G. Jung 11

The first interesting result is seen in Germany, where only nine IAAP members,
routers, and trainees answered the questionnaire (resulting among the lowest coun-
tries per response rate), while there was a high response rate among IAAP training
analysts, accounting for 38 respondents and therefore positioning itself at the top
of the list. This is an inverted trend compared with the rest of the countries, where
there was a lower response rate among IAAP training analysts than among IAAP
members, routers, and trainees. It is true that there are fewer IAAP training analysts
than IAAP members, routers, and trainees in the different IAAP Associations, but it
would be interesting to assess the results of the high or low number of training ana-
lysts who participated in the questionnaire. For example, in Italy, among all AIPA,
CIPA, and ARPA training analysts – that is, 305 individuals – only 13 answered
the questionnaire, accounting for 4.2 percent of all Italian IAAP training analysts.
It may be useful and interesting for IAAP Associations in the different countries to
calculate ex-post the percentage of training analysts who answered the question-
naire in each country.
Considering the results presented above, it appears that although IAAP members,
routers, and trainees, and IAAP training analysts consider active imagination to be a
meaningful component for C.G. Jung (95.3 percent and 90 percent, respectively) both
at theoretical and clinical level, they are not adequately informed about such practice.
Among those who answered the questionnaire, only 48.7 percent of IAAP train-
ing analysts experienced active imagination as patients, 69 percent experienced it
in training, and yet 81.9 percent use it in their clinical practice, showing that a large
number of IAAP training analysts use active imagination even though they may not
have personally experienced it during their analysis. This leads to a first interesting
question: since many IAAP training analysts use the practice of active imagination
without having experienced it as patients or trainees, are we truly able to provide the
skills necessary to use active imagination in our clinical practice? Are we sufficiently
trained to pass on the knowledge and practice of active imagination to IAAP trainees?

In your opinion, did C. G. Jung consider

QUESTION: Active Imagination to be meaningful and
valuable in his clinical practice?
Overall:
% 4,7%

I believe it was very relevant

in C.G. Jung’s clinical practice.

I do not believe it was

paticularly relevant in
C.G. Jung’s clinical practice.

Figure 3 Percentage of IAAP member, router, and trainee respondents who be-
lieve and who do not believe C.G. Jung considered active imagination to
be meaningful and valuable in his clinical practice.
12 Chiara Tozzi

QUESTION: In your opinion, did C. G. Jung consider Active Imagination

to be meaningful and valuable in his clinical practice?
Overall:
%

I believe it was very relevant

in C.G. Jung’s clinical practice.
I do not believe it was
paticularly relevant in
C.G. Jung’s clinical practice.

Figure 4 Percentage of IAAP training analyst respondents who believe and who
do not believe C.G. Jung considered active imagination to be meaningful
and valuable in his clinical practice.

Only 38.1 percent and 36.3 percent of all members, routers, and trainees are
familiar with the scientific literature on active imagination in international jour-
nals and in their country’s accredited journals of analytical psychology. For IAAP
training analysts, the percentages account for 54 percent and 50.6 percent, leading
us to think there may be a lack of stimuli on the subject. This seems to once again
confirm that the knowledge on active imagination is not sufficiently widespread
among members, routers, and trainees, nor among training analysts.
Moreover, 55 percent of IAAP training analysts say active imagination is consid-
ered to be an optional component in training.
Of the respondents, 56 percent believe it is seen as a secondary method; how-
ever, in reality, 78.8 percent of IAAP members, routers, and trainees consider it a
fundamental component in training.
The percentage asking for more practical exercises on such content through ex-
periential workshops is 83.7 percent. In addition, 42.2 percent of IAAP members,
routers, and trainees consider active imagination to be a fundamental component
in training, showing a further discrepancy between how individuals perceive active
imagination and how they believe it is considered in the IAAP Association they
are part of. Actually, 78.8 percent of IAAP members, routers, and trainees say that
active imagination is a fundamental component in training, but only 33 percent of
training analysts believe active imagination is considered to be an essential method
in the Association they are part of.
Data analysis validates the research hypothesis highlighting, among others, a
big discrepancy in the confidence shared by Jungian analysts who consider active
 Active Imagination: The Special Legacy of C.G. Jung 13

QUESTION: Is Active Imagination considered to be

an optional component in training?

Overall:

No
Yes
No answer

90%

Figure 5 Percentage of IAAP training analyst respondents who believe and who
do not believe active imagination is considered to be an optional com-
ponent in training.

QUESTION: Do you consider Active Imagination

a fundamental component in IAAP training?
Overall:
%

I don’t know
No
Yes
No answer

90%

Figure 6 Percentage of IAAP member, router, and trainee respondents who be-
lieve, who do not believe, and who do not know if active imagination is
considered to be a fundamental component in training.
14 Chiara Tozzi

imagination to be a fundamental practice both for C.G. Jung and for the Jungian
community, and the current lack of knowledge, spread, use, and relevance of such
practice by IAAP Jungian analysts and in IAAP training.
I believe all this material could represent some interesting food for thought on
the relevance given to active imagination within the IAAP, both as theoretical
knowledge and as clinical practice, and as a teaching subject in IAAP training.

Content and Aim of the Book

The aim of this book is to broaden and enhance the precious value of the special
legacy of C.G. Jung, which he himself defined as active imagination, through a
collection of unpublished contributions by some of the brightest Jungian analysts
and renowned representatives from the disciplines of Art, Culture, Physics, and
Neurosciences from different parts of the world.
About one century after the creation of C.G. Jung’s active imagination, these
voices put together give life to a multifaceted representation of active imagination,
showing its many characteristics at a theoretical level, the different settings and
ways in which such practice is currently used and experienced, and the resonance
that active imagination can have in the scientific, artistic, and cultural fields.
The book not only targets the Jungian community, psychologists, and psycho-
analysts in general, but also anyone in the world who may be interested in discover-
ing the possible correlation between an original and fascinating psychotherapeutic
practice such as active imagination, and the content in the fields of Neuroscience,
Physics, Cinema, Literature, Painting, Music, and Dance.
I invited both fellow Jungian analysts and friends from the worlds of Art, Cul-
ture, Physics, and Neurosciences to work on this book, with the goal of offering the
reader a kaleidoscopic representation of the extent to which active imagination, as
conceived and experienced by C.G. Jung, is present. I allowed all authors complete
freedom, and at the same time made myself available to collaborate, clarify, amplify,
and listen. In fact, I can say I supported the writing of the chapters for at least half of
the participants, helping them step by step. For me, this was a true way of diving into
varied and differentiated fields and contents, always fascinating and interconnected.
The division into two volumes is intended to facilitate the reader’s orientation
in different subjects, but the areas and themes dealt with in both volumes are ab-
solutely related to one another. Indeed, I hope that each chapter pushes readers to
look for the possible amplification and completion in the others.

Active Imagination in Theory, Practice and Training.

The Special Legacy of C.G. Jung
This volume mainly addresses the history, theory, clinical practice, and personal
experimentation, as well as reflections on the teaching of active imagination. By
simultaneously addressing the theoretical aspects and the practical application of
active imagination through the method of “authentic movement”, the last chapter
is a sort of trait d’union between the first and the second volume.
Another random document with
no related content on Scribd:
 (b) Retardation of the general oxidation changes of the body,
resulting in malnutrition and general loss of tone.
(c) Establishment of intoxication, with the generalized affections,
paresis, etc.
If three such periods can be recognized, as no doubt they can, as
divisions of the time during which lead gradually affects the tissues,
the symptoms in the more severe cases would be expected to be
those associated with the more prolonged exposure. This, no doubt,
is true to a limited extent, more particularly in industrial poisoning,
depending for its development on a long-continued dosage of lead in
minute quantities, and for the most part of metallic lead. On the other
hand, with some of the salts of lead, notably the hydrated carbonate,
acute disease may take place during the first stage—namely,
impregnation of lead—the determining factor then being either the
retardation of the elimination of lead, or a suddenly increased
quantity in lead dosage, or some intercurrent disease, or even
alcoholic excess, whereby a sudden large excess of the poison is
thrown into the general circulation.
The commonest type of paralysis occurring is the one affecting the
muscles of the hands, which may for a considerable time show some
diminution in their extensor power before the actual onset of the
disease takes place. The onset of paralysis is practically always
unaccompanied by pyrexia; the only occasions in which pyrexia may
be associated with the onset of the attack are those cases in which
some secondary cause determines the paralysis, and the pyrexia in
these instances is due to the intercurrent disease, and not to the
lead infection.
Although weakness of the extensor muscles of the hands may be
present in persons subjected to lead absorption for a considerable
time, the actual onset of the disease itself is frequently sudden; but
in the majority of cases it is distinctly chronic, and is rarely, in the
case of paresis, associated with any definite prodromal symptoms.
Prodromal symptoms have been noted, such, for instance, as
lassitude, general debility, and more especially loss of weight.
Cramps of the muscles the nerve-supply of which is becoming
affected, alteration of the skin over areas corresponding to definite
cutaneous nerves, hyperæsthesia, anæsthesia, or analgesia, may
occasionally be present. Neuralgic pains have also been described,
but these are inconstant, and generally of the arthralgic type related
to the periarticular tissues of joints rather than to pain in the course
of the nerves. The pain is rather of the visceral referred type than a
definite neuralgia. Tremor is, however, frequently associated with the
preliminary condition of paresis, and in several cases variations in
the amount of weakness of the extensor muscles of the wrist have
been noticed, as far as can be estimated clinically without the use of
a dynamometer. Associated with this weakness is tremor of a fine
type, often increased by movement (intention tremor), and in every
case more marked during the periods of increased weakness.
Instances have occurred where definite wrist-drop followed after a
prolonged period of weakness; in others the weakness has
temporarily cleared up for six months, and no difference could be
determined in the extensor power of the two wrists; while in others,
again, the weakness is progressive, but slight, and insufficient to
warrant the removal of the workman from his occupation. Again,
progressive weakness may remain a symptom of the wrists of
workmen for years.
The Forms of Lead Paresis.—The paralysis may be partial or
generalized, but the chief muscles affected are the extensors of the
wrists and the forearm, and the interossei of the hand. As a rule, the
first muscles to be affected are the extensor communis digitorum
and the extensor indicis. The muscles of the shoulder—mainly the
deltoid—come next in order, followed by the muscles of the leg,
particularly the peroneus longus and brevis, with occasionally the
interossei of the foot; the muscles of the back, neck, and abdominal
walls, are occasionally affected, as are those of the larynx and
diaphragm, and it is of interest to note that Trousseau pointed out
that among horses employed in lead works paralysis of the superior
laryngeal nerve often occurred.
Considerable difficulty is experienced in estimating the reason of
the predilection of lead for the musculo-spiral nerve, this being the
nerve mainly affected in wrist-drop. Owing to the fact that the
supinator longus receives an additional nerve-supply to the musculo-
spiral, this muscle frequently escapes paralysis when the whole of
the other extensors of the hand are involved. Moreover, the
predilection for given nerves differs in different animals, and one of
us (K. W. G.) has found experimentally that in cats the first nerve to
be affected is the anterior crural supplying the quadriceps extensor,
whilst the second group of muscles affected are the spinal muscles,
particularly in the lumbar region.
Among the speculations which have been made with regard to this
predilection for definite groups of muscles supplied by one nerve,
Teleky[4] examined forty cases of paralysis with special reference to
Edinger’s theory—namely, that the function of muscles (and of other
organs) breaks down under certain circumstances before the strain
set upon them. In this way Edinger explains paralysis following lead
poisoning as being due to excessive strain on the particular group of
muscles affected, based on a consideration of the relative volumes
and weights of the muscles of the hand and forearm, and the
demands made on the several groups, flexors, extensors,
supinators, etc., by the coarse or fine work respectively demanded of
them in industrial employment. He concludes that—
1. Of the forearm, the flexors (triceps, anconeus, extensors,
biceps, brachialis anticus, and supinator longus) possess a high
degree of capacity for work, but are not called into play mainly in the
execution of fine work; while the supinators are characterized by
great mass, and are brought into play mainly in work of coarse and
heavy nature, and not during fine manipulations.
2. The muscles concerned in pronation are of small capacity for
work, and are not called on for sustained work.
As for the muscles acting on the wrist and hand, he concludes that
the extensors (carpi radialis longior and brevior, carpi ulnaris, and
the extensors of the fingers) are powerful, and much exceed in
capacity for work the flexors (flexor carpi radialis, flexor carpi ulnaris,
the flexors of the fingers, etc.), but in all fine manual work, and
specially where close grasping movements enter into association
with the flexors, external strain is put upon them, whilst the flexors
merely support their action.
The extensor communis digitorum is the weakest of all the long
finger muscles; its volume is hardly one-fourth that of the
corresponding flexors, and while it acts only on the first of the
phalanges, the flexors act on all three. In all fine work they are called
on for heavy strain, especially the interossei and the lumbricals, but
in harmony with the long flexors when grasping movements are
performed. The small muscles of the fingers have nearly the same
mass as the extensor communis, and in all fine movements the
grasping efforts are taxed severely; but their play is under
considerably more favourable physical relations than that of the
extensors, whilst in addition they are aided in their work at times by
the long flexors. The chief adductor muscle of the thumb (extensor
metacarpi pollicis) is particularly powerful; the other extensors of the
thumb are very weak, and work under unfavourable physical
conditions, but are supported in their action by the strong abductor
muscle. The muscles of the abductor, opponens and flexor brevis, in
the complicated work thrown on the thumb in manipulation, are much
exerted, so that the effects of overexertion show themselves first in
this region.
Thus, Edinger maintains that the muscle-supply of the arm is
designed for coarse heavy work, the muscles of the fingers and the
hand having to carry out more work than can be expected of them
from a consideration of their volume and their physical action.
The commonest form of lead palsy, the antibrachial type of
Déjerine-Klumpke[5], is explicable from consideration of overexertion
of the particular group of muscles named. The supinator muscle,
supplied also by the musculo-spiral nerve which serves the
paralyzed muscles, escapes because of its size, and the fact that
functionally it belongs to the flexor group, and the first-named reason
also, explain the frequent escape of the long abductor of the thumb.
Teleky[6] investigated thirteen slight cases of the antibrachial type.
In one both hands were affected, in one the left only, and in all the
others the right only—facts which he thinks bring out the rule of
causation by employment. Of fourteen painters, three had the right
forearm affected only, the other eleven both right and left, but always
more marked in the right. Amongst them he cites cases where the
shoulder muscles were paralyzed, which he considered was due to
the extra strain of unusual employment, involving a raising of the
arms above the head, or lying on the back painting the under parts of
carriages. In several of the painters the index-finger was the least
affected, by reason of the less exertion thrown on it by the position
assumed in holding the brush between the second and third fingers.
The long abductor, probably because of its size and power, is in no
case completely paralyzed.
In file-cutters he insists that the predominant share, falling on a
single or on several small muscles of the hands, makes the early
appearance of paralysis of the small muscles the characteristic sign.
In this connection we have frequently observed decrease in the size
of the thenar and hypothenar eminences amongst lead rollers; in
fact, in the majority of lead rollers who have followed their occupation
for a large number of years the flattening of both thenar and
hypothenar eminences is well marked, but it is only fair to point out
that in these cases very considerable stress is thrown on the muscle
of this part of the hand by the pressure of the lead plate in pushing it
inwards into the roller and grasping it on its appearance back again
through the roller, and that, further, the use of large and clumsy
gloves with all the fingers inserted into one part, and the thumb only
into the other, tends to produce inaction of portions of the lumbricals
and of the opponens pollicis, and may, therefore, from purely
mechanical reasons cause damage to this part of the hand.
Teleky[7] cites cases of right-sided paralysis of the adductor brevis
pollicis supplied by the median nerve, and partial paralysis of the
long extensors and of the extensor ossis metacarpi pollicis supplied
by the radial nerve, and in one or two cases complete paralysis of
the thenar muscles and adductor, whilst the extensors of the fingers
and wrists were only partially paralyzed. The cases all occurred in
lead capsule polishers. This particular selection of muscles is clearly
the result of the peculiar movement necessary in polishing the
capsules of bottles on a revolving spindle, involving specially the use
of the opponens muscle.
This observation of Teleky’s is in direct accord with the observation
quoted above of the hands of persons engaged in lead rolling.
In the lower extremity, paralysis of the muscles associated also
with paralysis of the adductor and extensors of the thumb was found
by Teleky in a shoemaker who had contracted plumbism by the use
of white lead. He explains this lower extremity paralysis by the
exertion thrown on the adductor muscles of the thigh whilst holding
the shoes.
 In children affected with lead palsy the lower extremities are more
frequently paralyzed than the upper, due to the relatively greater
strain in childhood on the legs than on the arms.
Edinger’s theory, supported as it is undoubtedly by Teleky’s
observations, is a matter of the greatest importance in the production
of paralysis; for if we accept the view that lead is a poison that has a
selective power on certain nerves, we have still to consider which is
the greatest force, the selection of certain groups of muscles or the
effect of functional action. The theory of muscular overexertion
certainly falls in with the type of paralysis, and Teleky has
undoubtedly shown that under certain circumstances, by special
exertion of other muscle groups not usually affected, these muscles
alone, or to a greater extent than those usually affected, are involved
in the paresis. If, therefore, lead has a selective action, which is
exceedingly doubtful, it must be very slight.
Such selective action is, of course, exceeded by a functional
activity which brings about the affection of those nerves which supply
the muscles most used. If, therefore, we judge of paralysis as being
due to the selective action of lead on certain nerves, we are met at
once with the objection that the muscles affected do not always
correspond to such a nerve distribution, and that muscles supplied
by other than the musculo-spiral nerve are affected by paralysis.
Careful consideration of the chapter on Pathology, and more
particularly of the histological findings described, in which the
preliminary action of lead is found to be typically and invariably on
the blood, setting up degenerative changes microscopical in size and
limited in area, affecting the vessel walls and producing a yielding of
the vessel, determining minute microscopical hæmorrhages
distributed, not necessarily in one position of the body, but all over
the body, and peculiarly in the case of the cat affecting those
muscles called upon to perform sudden and violent movement—
namely, jumping—enables us to regard such microscopical
hæmorrhages as an adequate explanation of the association of
paralysis in muscle groups, functionally related to various trades and
industrial processes.
It may be argued, and we think with considerable reason, both
from pathological and clinical findings, that, as muscular exertion is
apparently associated with the onset of paralysis, particularly in
those muscles which may be regarded as physically somewhat
inadequate to the work they have to perform, and that, as the
paralysis is associated with definite functional groups of muscles,
and to a curious extent varies according to the trade in which the
sufferer is engaged, therefore greater stress thrown upon the
muscular tissue at some period or another during occupation
determines the microscopical hæmorrhage in the nerve supplying
the muscles, or in the muscle itself, so that the paralysis affects just
such muscles as have an increased strain thrown upon them. It does
not necessarily follow that the preliminary initial hæmorrhage
occurring should be a large one—in fact, from the whole of the
histological history, hæmorrhages are exceedingly minute; neither
does it follow that it is essential for such hæmorrhages to take place
in the whole length of the nerve itself; but it is only necessary that the
finer branches of the nerve should have their venioles or arterioles
affected, and it is of course in the finer branches particularly, as has
been pointed out in relation to the venioles, that degeneration of the
intima of the vessels takes place.
Finally, the effect of early treatment on lead palsy tends to bear out
this theory. If a case of lead palsy be treated in the early stages, the
clinical course of the case is good; increased paralysis generally
takes place in the first week, and, where, perhaps, only two or three
fingers are involved when the case is first seen, spreads generally to
other regions within a week, and the whole hand is affected; but from
this moment onwards improvement takes place on the application of
suitable treatment, and, if continued, almost invariably results in the
entire recovery from the paresis.
There is little doubt that this is the true explanation of the ordinary
paresis of lead poisoning, and a very great deal more evidence is
required to combat it and to prove the selective action of lead upon
individual nerves, since the theory of hæmorrhage does not owe its
origin to conjecture, but is based on clinical and histological
examination of early cases of poisoning.
In attempting to find a cause for the paralysis of the hands so
commonly present in painters, it has been suggested that lead is
absorbed through the skin, and affects the nerves at their junction
with the muscles, setting up a peripheral neuritis [Gombault[8]]. The
theory breaks down at once when such commonly-occurring
affections as paralysis of the ocular muscles, paralysis of the
peroneal type, paralysis of the muscles of the shoulder, etc., are
considered.
For the convenience of description lead paralyses are generally
divided into a series of groups, the grouping varying according to the
function of the various muscles rather than to their anatomical
grouping. The various types of paralysis have to be considered in
detail:
1. Antibrachial Type (Déjerine-Klumpke—Remak).—The first
muscle affected is the extensor communis digitorum, with dropping
of middle and ring fingers, while extension of the first and fourth is
possible because of their separate muscles of extension (extensor
minimi digiti and extensor indicis). Paralysis may be limited to these,
and not advance farther, but it is common to see these two muscles
primarily affected, and for other muscles to become involved after
the patient is put on treatment, although exposure to lead has
ceased. Usually, however, the paralysis advances, involving the
extensors of the index and little fingers, so that the basal phalanges
of the four fingers cannot be extended. The long extensor of the
thumb is next involved, but this may be delayed. The two terminal
phalanges are still able to be extended by the interossei (as shown
by Duchenne) when the basal phalanx is passively extended on the
metacarpal. Abduction and adduction of the fingers also remain
unaffected. The wrist muscles are affected next. The hand remains
in semi-pronation, and when hanging down forms a right angle with
the forearm, the fingers slightly flexed with the thumb towards the
palm, and the hand deflected to the ulnar side. In grasping an object
the flexors remain unaffected, the wrist is much flexed owing to the
shortening of the flexors in consequence of the extensor paralysis.
The hand cannot pass the median line. The long abductor of the
thumb—that is, the extensor ossis metacarpi pollicis, also known as
the “extensor primi internodii pollicis”—is only very rarely involved,
but has been described as being the muscle alone involved in the
paralysis affecting persons engaged in polishing lead capsules.
2. The Superior or Brachial Type (Remak).
—The muscles affected are those of the Duchenne-Erb group—
namely, the deltoid, biceps, brachialis anticus, and supinator longus.
The supra- and infrascapular muscles are also as a rule involved,
but the pectoralis major rarely. This type of paralysis is usually found
in old cases associated with other forms of paralysis, but may be
found as a primary affection (as already noted amongst painters);
sometimes the deltoid is the only muscle affected, with diminution in
electrical contractility of the other muscles of the group.
The arm hangs loosely by the trunk, with the forearm semi-
pronated. The arm cannot be raised, nor can the forearm be bent on
the upper arm. Extension is unaffected, as the triceps is never
involved. Supination is impossible because of paralysis of the
supinator brevis. Movement effecting rotation of the shoulders is
involved, due to the paralysis of the supra- and infra-spinatus.
Electrical reactions are said to be less marked in the brachial than
the antibrachial type, and complete loss of faradic contractility is
rare; but in one of the three cases described below, in which
electrical reactions were carefully tested, the right deltoid showed
entire loss of contractility to faradism.
3. Aran-Duchenne Type.—The muscles of the thenar and
hypothenar eminences and interossei are affected. This type of lead
paralysis may be distinguished from progressive muscular atrophy
by the electrical reactions, and the fact that the atrophy is
accompanied by more or less pronounced muscular paralysis. The
atrophy is almost always most marked, and advances pari passu
with the paralysis. This form may occur alone, or be complicated with
the antibrachial type, which is the most common. It is seen in file-
cutters as the result of overstrain of the muscles in question.
Moebius[9], in his observations on file-cutters, noted in one case
paralysis of the left thumb, with integrity of the other muscles of the
left upper extremity. Opposition of the thumb was very defective;
there was paralysis of the short flexor and of the adductor and
atrophy of the internal half of the hypothenar eminence. Reaction of
degeneration was noted in the muscles named, but not in the
extensors of the fingers and wrist. In another case, in addition to
feebleness of the deltoid, flexors of forearm on the upper arm, and
small muscles of hand, there was paralysis and atrophy of the
adductor of the thumb and first interosseous and paralysis of the
opponens.
4. Peroneal Type.—This is a rare type, and nearly always
associated with the antibrachial or with generalized paralysis. In the
former the paralysis is slight, especially when it affects the psoas;
but there is predilection for certain groups of muscles, especially the
peroneal and extensor of the toes, while the tibialis anticus escapes.
Hyperæsthesia, or more rarely anæsthesia, precedes the onset.
The patient walks on the outside of the feet, has difficulty in
climbing stairs, and cannot stand on the toes. The toes drag on the
ground in walking, so that the foot has to be swung round at each
step, and the inner side is lifted in excess by the action of the tibialis
anticus, with uncertainty in gait. If walking is continued, the toes drag
more, and “stepping” gait is assumed by bringing into action the
muscles of the thigh. The foot cannot be flexed on the leg; abduction
of the foot and extension of the basal phalanx of the toes is
impossible. Later the peroneal muscles, extensor communis of toes,
and extensor of great toe, are paralyzed, from which fact arises the
difficulty of walking and of descending stairs, as the whole weight of
the body is supported then by the tibialis anticus. This type
corresponds with the antibrachial type of the upper extremity. If the
tibialis anticus is paralyzed, it is in association with the
gastrocnemius.
5. Paralysis of Special Sense Organs.—Tanquerel[10] called
attention to the aphonia of horses in lead works, necessitating
tracheotomy, and Sajous[11] described adductor paralysis of the
glottis in a house-painter. Morell Mackenzie[12] also described
unilateral paralysis of the adductors in persons suffering from lead
poisoning, whilst Seifert[13] particularly describes a curious case in
which paralysis of the transverse and oblique arytenoid muscles
prevented contraction of the cord in its posterior quarter, and in a
second case of paralysis, affecting the posterior crico-arytenoid
muscles on both sides, the adductors remained unaffected. What is
still more interesting in Seifert’s case is the fact that at the post-
mortem old hæmorrhages were found in the mucosa of the
arytenoids and aryepiglottidean folds. Occasionally sensory paralysis
may be found in the special sense organs—such, for instance, as
loss of taste, loss of smell, and, in addition, diminished power of
hearing—but these defects rarely if ever occur unless accompanied
by distinct mental changes and generalized paralysis.
6. Eye.—Poisoning affects the eye in two ways:
(a) Defects of the visual mechanism.
(b) Defects of the muscular mechanism of the eye.
Lockhart Gibson[14] describes a large number of cases of paralysis
of the muscles of the eye met with amongst children in Queensland.
The cause was traced to the painted railings near which the children
had been playing. The white lead paint had somewhat disintegrated
under the action of the sun’s rays, forming an efflorescence; the
children admitted to have rubbed the paint and then sucked their
fingers.
Between July, 1905, and 1908, sixty-two cases of plumbism in
children were admitted to the children’s hospital, and of these sixty-
two cases thirteen had well-marked ocular symptoms. The paralysis
of the muscles of the eye was almost invariably one of the external
rectus, but other muscles were at the same time affected;
occasionally paralysis of the whole of the oculo-motor muscles was
seen with the exception of the superior oblique. It is worthy of note
that amongst these children a very large number suffered, in addition
to their eye paralysis, with foot-drop and wrist-drop, and, on the
whole, suffered from foot-drop to a much larger extent than from
paralysis of the hands.
Galezowski[15] describes paralysis of accommodation of the eye,
and in cases described by Folker[16] some amount of orbital
paralysis was also present.
7. Generalized Paralysis.—These types do not differ in form
from the previously described types, except, perhaps, as regards
their rapidity of onset. Where the onset is slow (chronic) the subject
is usually one who has been previously affected with paralysis of the
extensors of the hand, followed by development of the paralysis in
the shoulders, hand, leg, thorax. In the acute form, paralysis may
affect all the muscles in a given limb or group, and reduce them in a
few days to a complete condition of paralysis. In extreme cases the
patient lies on the back and is incapable of rising, and sometimes
even unable to eat. The intercostals, diaphragm, and larynx, are also
affected, while there is generally dyspnœa and aphonia. The
muscles of the head and neck appear to escape. In these acute
cases, pyrexia may be a common symptom.
Electrical Reactions.—The diagnosis of the affected muscle is
greatly assisted by careful examination of
all the muscles in the affected physiological group by means of the
galvanic and faradic currents. The battery for the purpose of testing
the electrical reactions must have an available electromotive force of
over 40 volts. A battery of thirty-two Leclanché dry cells is ample. For
the faradic current, a small induction coil operated by two Leclanché
cells is sufficient. One large, flat electrode should be used, and
several smaller ones.
The faradic current should be used first, as it stimulates the nerves
directly, and the muscles only indirectly, through their nerve-supply.
Each nerve trunk should be examined systematically. The motor
points correspond for the most part with the points of entry of the
motor nerves into the muscles which they supply. A small electrode,
either a button or a small disc about the size of a sixpence, should
be used for the examining electrode, while the larger electrode
should be placed either on the abdomen or between the shoulders.
The electrodes should be well soaked in normal saline.
The intensity of the minimum current required to produce a
contraction for each point should be noted, and compared with the
effect of a similar current on the opposite side of the body.
The reaction of degeneration of the faradic current consists in no
contraction at all being elicited, even when a very strong current is
employed. If there be unilateral wrist-drop in the left hand, consisting
of loss of power of the extensor communis digitorum on that side, no
movement of the muscle is produced at all when the electrode is
placed across the motor points of the muscle. These are situated to
the outer side of the arm when the dorsum of the hand is uppermost,
about 1¹⁄₂ to 2 inches below the olecranon. The same quantity of
current, when applied to the unaffected muscle on the opposite side,
produces a brisk reaction.
Having observed the effect with the faradic current, and the results
having been recorded, the continuous current is used, and the
electrodes made use of in an exactly similar fashion. When a small
electrode is used, the superficial nerves and muscles are more
stimulated than those lying deeply. It is necessary, therefore, to begin
with a small current and gradually increase it until the individual
muscle responds.
The strength of the current employed is registered by means of a
milliampèremeter.
With the continuous current quantitative as well as qualitative
alterations may be determined, and with the quantitative change of
the galvanic current the muscular excitability is increased,
contraction following the application of a weaker current than is
necessary to produce it in health or in the sound muscle on the other
side of the body.
With the qualitative change, the contraction is no longer sharp, but
sluggish. The anodal closing contraction is elicited with a weaker
current than kathodal closing contraction, so that ACC>KCC.
The quantitative change depends partly on the nutrition of the
muscle; the qualitative change depends on the fact that the nerve no
longer regulates the character of the contraction, and also to a small
extent is the result of changes in the muscle itself.
In a complete reaction of degeneration in an affected muscle,
reaction to the faradic current is absent, contraction to the galvanic
current is sluggish, and is produced with a smaller current in the
anode than the kathode.[A]
[A] The kathode, or negative electrode, is attached to the zinc rod; the
anode, or positive electrode, to the copper or carbon.

As the nerve lesion passes away, the voluntary contraction

generally begins to return before the nerves show any reaction to
electrical stimulus.
The following three cases in which the electrical reactions of the
muscles were determined, give examples of typical cases of lead
paresis. In No. 3, owing to the fact that the case was treated
immediately the paralysis occurred, complete recovery had taken
place, and, as will be seen, the electrical reactions have again
become normal.
 Case 1.—Litharge and blast-furnace worker. Employed in lead
works, where a large number of different metallurgical processes
associated with the recovery of lead from the ore were carried on.
Double wrist-drop, existing for eight years, untreated until some four
years after paralysis took place, when slight improvement occurred.
The electrical reactions show that the extensor communis digitorum
on the right side is completely degenerated, whilst the first
interosseous of the right side show reactions of degeneration. On the
left side the extensor communis digitorum showed normal but very
feeble reaction. This latter point is one of considerable importance if
early hæmorrhage accounts for lead paralysis, for if the nerve itself
was completely destroyed, or if, as was the case, the muscle
appeared completely paralyzed on inspection, obviously the nerve-
supply must be completely cut off if the lesion was due to destruction
of the nerve of the spinal cord or to the destruction of the lower
motor neuron. On the other hand, the presence of small localized
fibrillar contraction, found by the galvanic current, together with the
presence of a slight reaction to faradism, suggests that some small
portion of the nerve has remained unaffected, and that for this
reason certain portions of the muscle have not undergone
degeneration—a circumstance which can hardly be expected if the
cause of the paralysis is in the destruction of the whole of the nerve-
supply.

ELECTRICAL REACTIONS IN LEAD PARALYSIS. (CASE 1.)

Muscle. Galvanism. Faradism. Remark

M.A. M.A.
R. Deltoid K.C.C. 8 A.C.C. 8 Good Evidently
(anterior extensor
portion) commun
L. Deltoid K.C.C. 6 A.C.C. 9 Good digitorum
(anterior right side
portion) complete
degener
R. Deltoid K.C.C. 6 A.C.C. 9 Good First
(posterior interosse
portion) on right
L. Deltoid Good show
 (posterior reactions
portion) degener
R. Supinator K.C.C. 6 A.C.C. 10 Reaction Good On left s
longus brisk extensor
commun
L. Supinator K.C.C. 5 A.C.C. 6 Reaction Good digitorum
longus brisk shows
R. Extensor No reactions either A.C.C. or K.C.C.[15] No normal b
communis reaction feeble
digitorum contracti
L. Extensor K.C.C. 8 A.C.C. 12 Brisk, but Feeble
communis feeble reaction
digitorum
R. Extensor K.C.C. none A.C.C. 13 Brisk Good
primi at
internodii 13
pollicis
L. Extensor K.C.C. 6 A.C.C. 12 Reaction Good (but
primi brisk less
internodii than
pollicis right)
R. Extensor K.C.C. 8 A.C.C. 8 Brisk Good
carpi ulnaris Contraction
L. Extensor K.C.C. 8 A.C.C. 12 Brisk Good
carpi ulnaris Contraction
R. First K.C.C. 8 A.C.C. 6 Contraction No
interosseous slow reaction
L. First K.C.C. 6 A.C.C. 6 Brisk Good
interosseous contraction
R. Second K.C.C. 8 A.C.C. 10 Brisk Slight
interosseous Contraction reaction
L. Second K.C.C. 6 A.C.C. 8 Brisk Good
interosseous Contraction
R. Third K.C.C. 9 A.C.C. 6 Brisk Slight
interosseous Contraction reaction
L. Third K.C.C. 6 A.C.C. 8 Brisk Slight
interosseous Contraction reaction
R. Fourth K.C.C. 8 A.C.C. 6 Brisk Slight
 interosseous Contraction reaction
L. Fourth K.C.C. 10 A.C.C. 9 Brisk Good
interosseous Contraction

ELECTRICAL REACTIONS IN LEAD PARALYSIS. (CASE 2.)

Muscle. M.A. Galvanism. Faradism. Remark

R. Deltoid 9 Slow reaction A.C.C. > K.C.C. No Reaction o
reaction degener
L. Deltoid 9 Slow reaction A.C.C. > K.C.C. Slow
reaction
R. Extensor 9 Slow reaction A.C.C. > K.C.C. No
communis reaction
digitorum
L. Ditto 9 Slow reaction No
reaction
Ante brachial
and brachial
groups give
normal
reaction

ELECTRICAL REACTIONS IN CASE OF RECOVERED WRIST-DROP. (CASE

Muscle. M.A. Galvanism. Faradism. Remark

R. Extensor 9 Good reaction K.C.C. > A.C.C. Good All muscles
communis reaction react we
digitorum both cur
L. Ditto 9 Good reaction K.C.C. > A.C.C. Good no sign o
reaction any reac
of
R. Extensor 9 Good reaction K.C.C. > A.C.C. Good degener
ossis reaction
metacarpi
pollicis
L. Ditto Good reaction K.C.C. > A.C.C. Good
reaction
R. Deltoid Good reaction K.C.C. > A.C.C. Good
reaction
L. Deltoid Good reaction K.C.C. > A.C.C. Good
 reaction
R. Extensor Good reaction K.C.C. > A.C.C. Good
carpi ulnaris reaction
L. Extensor Good reaction K.C.C. > A.C.C. Good
carpi ulnaris reaction
R. Interossei Good reaction K.C.C. > A.C.C. Good
reaction
L. Interossei Good reaction K.C.C. > A.C.C. Good
reaction

This case is a typical one of the anterior brachial type, showing

partial recovery of function. The man is able to grasp, although the
wrist becomes strongly flexed in so doing.
Case 2.—We are indebted to Dr. Gossage for this case, which
was presented at the Out-patients of the Westminster Hospital; and
to Dr. Worrell, who made the electrical investigations. We are further
indebted to Dr. Worrell for the reports which are given in tabular form
of the electrical reactions of these three cases.
This is a case of brachial type, with weakness of both deltoids, and
the patient was unable to raise his right arm at the shoulder. It will be
seen that there is here also evidence that the electrical contractility
diminishes before the entire loss. It will be also noticed that the
supinators are unaffected.
Case 3.—These are the electrical reactions of a case which had
recovered. This man showed the ordinary anterior brachial type,
which came on suddenly, although he had shown distinct weakness
of wrists when forcible flexion was performed for nine months
previously, but there had been no obvious increase in the weakness.
He was immediately removed from his work, and within seven days
paralysis, which at first only affected the extensor communis
digitorum, had spread to the minimi digiti and the extensor indicis,
the opponens pollicis being also involved on the right side. He was
treated from the start with faradic current, and was instructed to use
the battery himself, which he did twice a day for a year. At the end of
two months he was sufficiently recovered to be given light work, and
at the time of taking the reactions his wrists have so far recovered
their power that we were unable to flex them forcibly.
The progressive weakness noted in the three cases has already
been referred to, and may be a prodrome of paralysis, but there may
be recovery without paralysis supervening.
Tremor.—Tremor may be observed in a large number of cases
of lead poisoning, and is invariably associated with paralysis,
although the symptom of tremor by no means always progresses to
definite palsy. Two types of tremor are described—fine and coarse—
and Gübler further describes a type of tremor which is both rhythmic
and intermittent. The tremor is usually distinctly increased on
attempting to grasp or point the hand (intention tremor), but it is
difficult to separate tremor from alcoholic tremor, and, further, it must
not be forgotten that persons engaged in arduous work may show a
certain amount of tremor due to muscular fatigue. Persistent tremor,
however, is a symptom that is always to be noted and carefully
watched.
Of the types of paralysis, the antibrachial is the most common,
and, secondly, probably the brachial. The least common is the
peroneal. The table on p. 54 shows the distribution of cases of
paralysis, so far as they can be made out from reports received
since 1904.
Closely associated with paralysis are affections involving the brain.
Tanquerel, in his classical description of affections of the brain
associated with lead poisoning, gives the following classification:
1. Delirium.
2. Lead mania.
3. Psychic depression.
4. Coma.
5. Convulsions, saturnine eclampsia, or epilepsy.
There is probably a very considerable relationship between
insanity and lead poisoning, as pointed out by Robert Jones[17], the
resident physician and Superintendent of Claybury Asylum.
Rayner[18] remarked that the compulsorily careful habits of life of
painters and lead-workers ought to protect them against vicious
habits, and should protect them against a too free indulgence in the
use of alcohol! Our own experience is that paralysis, and particularly
affections of the brain, occur in the majority of cases in persons who
are addicted to alcohol, and the experiments quoted in the chapter
on Pathology on the influence of alcohol in the production of
encephalitis in animals is strong presumptive evidence that alcohol is
one of the chief predisposing causes in the determination of
saturnine encephalopathy.
Encephalitis is given as a cause of death in the report already
referred to in 14·3 per cent. of 264 fatal cases. Amongst this number
encephalopathy accounted for 14·3 per cent., cerebral hæmorrhage
9·8 per cent., and paralysis 9·2 per cent. Now, all these are cases in
which cerebral lesions may be confidently stated to have existed,
which brings the total to 34·4 per cent. of deaths at least due to brain
involvement. We have already referred to the high incidence of
paralysis amongst file-cutters—40 per cent. as against 21·1 per cent.
for all industrial forms of poisoning.
When encephalitis occurs, it is usually an acute symptom, and
often develops before paralysis is set up, but as a rule is preceded
by a period of persistent headache, such headache being invariably
temporal or occipital.
Robert Jones, in his paper, states that of the 133 cases who, from
the nature of their work (painters, plumbers, etc.), were liable to lead
impregnation, 19 had signs of poisoning upon admission, whilst 22
had a distinct history of lead poisoning at some time or other. He
gives the following analysis of the mental condition:
Mania 37
Melancholia 33
Dementia 19
Dementia with epilepsy 10
Dementia with general paralysis 24
? General paralysis 7
Alcoholic mania 3
133

Savage[19] is of opinion that lead will produce any of the symptoms

of general paralysis of the insane, and may even be a contributory
cause of the disease, but no statistics are available of the
Wassermann reaction in these cases. Goodall[20] refers to the fact
that nerve poisons, such as syphilis, alcohol, and fevers, injury or
sunstroke, which are intermediate in fixity between alcohol and lead,
seem to have an intermediate influence in the production of general
paralysis.
Jones states that the mental symptoms found in the cases are to
be grouped amongst one or other of the following varieties:
1. Of a toxæmic nature, with sensory disturbances, which tend to
get well rapidly.
2. Hallucinations of sight and hearing, more chronic in nature,
which may be permanent. The delusions in this class are almost
invariably those of being poisoned or followed about, and are in the
main persecutory.
3. Those resembling general paralysis with tremors, increased
knee-jerk, inco-ordination, accompanied with listlessness amounting
to profound dementia, but which tend to get well.
Eye Changes.—Two main forms of eye change are to be found
amongst lead-workers. In the first place, temporary and sudden
amaurosis makes its appearance, due no doubt to vascular change,
either vaso-motor or hæmorrhagic. The trouble may occur in one or
both eyes, may come on gradually, the patient merely being unable
to distinguish letters or faces at a distance, or he may become
suddenly totally blind. In the majority of cases the affection
disappears under treatment, but in a small number of cases total
blindness persists.
Occasionally nystagmus may be seen, but is not a common
symptom; but dilatation of the pupils, quite apart from retinal
changes, is not unusual. Inequality of the pupils may be observed,
but partial dilatation of both pupils is more common, and is often
associated with early anæmia. Conjunctival hæmorrhages are to be
noted from time to time, without obvious cause, such as injury, etc.,
but in the majority of cases these have been associated with other
symptoms.
The first feature noticed in the eye is loss of brightness, and a
curious lack-lustre of the eyes of persons intoxicated by lead is one
of the general features making up the saturnine cachexia. Loss of
brightness of the eye is associated in many other diseases with