The purpose of this article is to review briefly a few of the many questions that have arisen directly or indirectly out of the interest taken of late years in the matter of the care and control of the feeble-minded, and to comment on some of the aspects of the legislative measure, known as the “Mental Deficiency Act,” which has ultimately resulted from that interest. Some reflections by the way on this subject, about which at the present moment there is necessarily but little practical activity, may, I trust, be regarded as not wholly inopportune. In offering to the readers of this Journal the following remarks on some difficulties that have been raised regarding the interpretation and working of the new Act, and in noting certain misconceptions and more or less irrelevant discussions that seem to have obscured the practical side of the subject, I have but the excuse of a long-continued interest in the matter of the due recognition of mental failure in all its varieties, and of my personal experience, gathered from the study of criminals, touching the part played by mental defect or disorder as a factor in the production of crime. These notes, which are at least meant to be practical, will therefore tend to circle chiefly round the questions of the actual diagnosis of such mental defect in persons of all ages as is now officially registered under the term “mental deficiency,” and of the relation that seems to exist between mental defect generally and criminality.

Gentlemen, in providing this paper I have felt many difficulties, for, while wishing in no way to protect shirkers, I wanted to avoid sending men into the army who were almost certain to break down under training, or at the front.

Through the kindness of Dr. Mercier we have been favoured with an advanced copy of the first instalment of a new work recently completed by him on the subject of Causation, with special reference to causes of death and causes of insanity. Owing to conditions now existing in consequence of the war, with, as a result, an extreme scarcity of suitable literary material for publication, as explained in the October number of the Journal, the Editors have had to face quite unprecedented difficulties; and they wish here to express their acknowledgments to Dr. Mercier for so generously coming to their aid in what may almost be termed a crisis in the history of the Journal. The second (and final) instalment of Dr. Mercier's book will appear in the April number.

Unquestionably the most usual and frequent ground for assuming a causal relation which is not immediately apparent is the similarity of the case in hand to other cases in which the causation has been ascertained. As it is the most frequent, so it is the most direct application of the fundamental Axiom of Causation, that Like causes in like conditions produce like effects, from which we obtain, by a logical process that is unknown to logicians, the immediate inference that Like effects in like conditions are due to like causes. It is by the application of this method not only that causation is most often established, but also that some of the most important discoveries of causes in the various sciences have been made. It is in perpetual use, both in the most recondite problems of science, and in the commonest affairs of daily life.

There is a class of individual loose upon society whose presence and significance in our midst seems, as yet, insufficiently and improperly appreciated. These people are usually of pleasant address, with all the outward show of civil social observance; they are fluent of speech, readily adaptable to circumstances, superficially in every way most plausible. How does it come, then, that on closer acquaintance they prove to be the scourge of their relations and friends; that many of them have a prisoner's acquaintance with the police courts; that they are frequently embezzlers of money; are guilty of theft, drunkenness, and immorality of every kind; that slander, with all its miserable train of disintegrating influences, emanates from them as a miasma? Punishment is no deterrent to their anti-social activities; they are supremely unaffected either by the teachings of past experience or the forewarnings of future suffering.

Ten years ago I was requested by the Secretary of the Medico-Psychological Association to open a discussion at the annual meeting of the Association on this subject. It was then regarded by some asylum medical officers as “the topic of the hour,” largely because of certain views on administration which I had expressed, and certain innovations in methods I had made at the Stirling District Asylum.

Ladies and Gentlemen,—I wish your President, especially as you are condemned to abide under his aegis for a second year, had been a man able to enthrall you with some lofty theme appropriate to this time of stupendous events.

All the experiments for this investigation were carried out by me in the Bacteriological Laboratories at Guy's Hospital, and my thanks are due to Dr. Eyre, the Director, for having placed every facility at my disposal, and to Dr. Ryffel, the Chemical Pathologist, for his advice and assistance. I am also indebted to my Board of Management and to my Medical Superintendent, Dr. Caldecott, for their courteous permission to undertake this investigation in the case of patients resident under their care at the Royal Earlswood Institution, at Redhill, in Surrey.

The sceptics maintain with some show of plausibility that medical treatment—the therapeutics of mental disorder included—has made little progress with the passage of the centuries; and that what is called progress is really pretentiousness, and is more verbal than actual. Some of the new schools of dogmatists certainly give reason for criticism of this kind; they bandy high-sounding phrases one against the other, until the plain man becomes confused with the welter of verbiage. It were invidious to specify too accurately. Each one according to his predilections can annotate the context. If he favours the neologisms of that school in which the new oneiromancy and the modified confessional bulk so largely in their dealings with the mentally disordered, he will exempt them from criticism; and he who considers that treatment should pass along lines less airy and less tenuous will, for his part, look elsewhere for firm ground from which to aim his darts at the flitting shadows beloved of the practisers of psychomancy. Yet, all this granted, a look backwards suffices generally to convince us that, when ephemeral and transient notions are regarded in their proper perspective, there has been a real and valuable progression towards clarity and truth—even, in some cases it may be, attainment. If there is, therefore, such good to be derived from this process of retrospection, one may be forgiven for directing attention for a short space to former times. As we look backwards, however, we are almost dismayed at the similarities which we notice between the errors and follies of those who lived many centuries ago and those of our time. At the first glance it appears that almost do we move in a circle. The same old errors, the same old superstitions in other guises. We are almost prevailed upon to say, with La Bruyère, “En effet les hommes n'ont point changé selon le cóur et selon les passions, ils sont encore tels qu'ils étoient alors,” more than two thousand years ago. There seems to be little abatement of what were designated as the “animal passions”; and along with that there has been an accompaniment of credulity which the few master-minds have not been able to overcome. Superstition holds its ground in many civilised communities, and as to war—in a time like the present—it is needless to speak. Yet withal we are prepared to maintain that enlightenment is being brought about.

Our knowledge of whether a person is normal, or suffers from neuritis, or is a case of dementia praecox, is derived entirely from observations of how he reacts to his environment—that is, to various stimuli. The thought at the basis of these researches is that an attempt may be made to produce an environment where the results will be accurately recorded in a simple, direct way.

The purpose of this paper is to develop the thought that delusional formations fulfil a definite function; they are the expression of certain underlying trends in the individual, and they satisfy certain needs. At the present time there is a reaction against the tendency to regard classification as the ultimate aim of clinical psychiatry. While the separation of mental disorders into certain broad groups has its obvious uses, it is being recognised that classification in itself is not a very vital point, and it does not take us far in the understanding of our cases. Not only is each case a member of a particular group, but in a certain sense it is an entity in itself; the odd behaviour, the delusions and hallucinations, have an individual significance; they are the outgrowth of personal conflicts and aspirations, and the whole psychosis is no more than one form of reaction to experience.

It is just forty years since I first ventured to call in question the accepted doctrines of the causation of nervous diseases. In an article in the British and Foreign Medical and Chirurgical Review, an excellent quarterly now long defunct, I likened the imagination of physicians in this respect to the imagination of that fortunate sailor to whom was granted (nowadays we should say who was given) the fairy privilege of having three wishes fulfilled. After he had secured all the rum in the world and all the tobacco in the world by his first two wishes, he could think of nothing further to desire than “a little more rum.” So physicians, after they had attributed every known nervous disease to sexual excess and syphilis, had no explanation of a new disease to offer beyond a little more sexual excess. The only nervous diseases that were not then attributed partly or wholly to syphilis were tabes and general paralysis. Some five-and-twenty years ago, when an eminent physician was about to lecture upon the causes of insanity, I hazarded the conjecture that we should hear a good deal about masturbation, and I had no reason to repent of my prophecy. We may be pardoned a little natural exultation when we contrast the present state of ætiological doctrine with that which prevailed in those dark ages. We had then no more reason for our belief than Aristotle had for the belief that all heavy bodies tend to the centre of the universe, but now we know that the mental diseases that we used fondly to ascribe to sexual excess and syphilis are, in fact, due to repressed complexes and infantile incestuous longings. How foolish were our predecessors! How enlightened are we!

In studying a case of insanity, the family history of the patient is a matter of considerable interest. But it is often difficult to obtain reliable information on the subject. In such researches one has to contend with ignorance and prejudice. Many people know very little about their ancestors or collateral relations. And further, the idea that insanity is a disgrace so pervades all classes of society, that a man is shy of speaking about the mental condition of his relatives, if it should chance to be, or have been, diseased.

I much appreciate the honour of being allowed to supplement your more formal courses of study with regard to mental defectives by a few biographical particulars and personal reminiscences of one who may be designated as the pioneer in their training, and the earliest exponent of the educational principles essential to their mental development. I may add that the principles Séguin laid down some seventy years ago apply to a far wider range than the instruction of imbeciles, and I shall hope to show that his master mind anticipated many of the modern methods which of late years have been accepted by the educational world as recent discoveries. As Mr. Holman well puts it in the opening sentence of his admirable book (1) on Séguin (to which I would at once express my appreciative acknowledgments), “The world has not infrequently had to rediscover its great men after they were dead, though their works lived after them.” The voice of Séguin was indeed, in his own day, at any rate as far as general educational science was concerned, as of one crying in the wilderness, and was even derided by the self-satisfied educationalists of the time. His ideas were indeed in advance of the age in which he lived; but what joy would it have been to him to see a summer school of earnest students of the subject nearest to his heart!

Hitherto a difficulty in forming a just opinion as to the value of the colony treatment of epileptics has been the inability to keep trace of the patients after they have left the Colony. In connection with the Lingfield Colony (which has nearly 300 epileptic patients), an attempt has now been made to follow up, and obtain a report upon, those patients who have left the Colony during the last 4½ years. To this end a circular was sent to the different local authorities asking for their co-operation in this investigation, and thanks are due to them for their prompt response. The number of cases inquired into totalled 101. The number of reports actually received was 100, but 20 of these were blank, the patients having disappeared without leaving an address.

The problem of hysteria, although for some years past it has engaged the special attention of the best neurologists and psychologists, is yet very far from being solved. The chief object which authors have had in view at recent congresses has been to obtain a satisfactory definition of this affection. A definition, however, as Claparéde justly observes, being only a citation of the characters which constitute the nature of a thing, should be the crown and not the foundation of the study of any malady. Hysteria cannot, then, be defined without first establishing the nature of this affection, without studying the mechanism of its morbid phenomena. Now, an essentially pathogenic study of this disorder has not yet been made. It has been supposed to be the consequence of a narrowing of the field of consciousness (Janet), the suppression in consciousness of painful impressions of sexual origin (Freud), of suggestibility (Babinski), of an exaggeration of the plastic power of the imagination (Hartemberg), of torpor of the organic cerebral mechanisms (Sollier), of a tendency to reversion, to atavism (Claparéde), of disorder of the cortical or sub-cortical reflexes (Raymond), of an exaggerated emotional reflex (Bernheim), of perversion of the highest cerebral functions (Bastian); but it has not been explained by what mechanism all these conditions are produced, and provoke the morbid phenomena. It is just here that the chief difficulty of all these theories lies; it is the point by which we may judge of their respective value. Even if we assume, for instance, that hysteria is due to a limitation of the field of consciousness, what, we may ask, is the primary cause which determines this modification of the personality? By what mechanism does a suggested idea or a painful representation translate itself, or become converted, into somatic phenomena, or into an exaggerated emotional reflex? It does not suffice to tell us that this affection is characterised by a flexile suggestibility or by an exaggeration of a plastic imagination; we require also an explanation as to what determines the plastic properties in the case of these patients. What is the cause which induces the torpor of the organic functions of the brain as in Sollier's theory, the disorder of cortical or sub-cortical reflexes as in that of Raymond?

It was in 1862 that Maurice Raynaud first made public his description of the condition with which his name has since been associated, and his Thesis for the Doctorate in Medicine has now become a classic in medical literature (1). Although there may be meticulous critics who will dispute his claim to priority in the delineation of the disease-complex known as Raynaud's disease, there can be no doubt that it was he who first succinctly and clearly described the condition. To use a phrase which is apposite in dealing with such a subject—it was Raynaud who first drew a “line of demarcation” between the symptoms characteristic of his syndrome and those typical of gangrenes in general. In his own words, he was dealing with “a very limited corner of the general history of gangrenes.” In the present paper it is proposed to remain within still stricter limitations, yet even there the amount of clinical material is not inconsiderable. There is an additional interest, too, from the fact that Raynaud, especially in his later researches (2), became more and more convinced that the explanation of the peripheral symptoms should be sought in some change in the central nervous system.

The following investigation deals with 400 children (200 boys and 200 girls) between the ages of 7 and 14, considered by the teachers, and after examination by myself, to be dull and backward, but not to fall within the meaning of the definition of feeble-minded as given in the Mental Deficiency Act of 1913—i.e., persons in whose case there exists from birth, or an early age, mental defectiveness not amounting to imbecility, yet so pronounced that they require care, supervision, and control for their own protection, or for the protection of others; or in the case of children, that they by reason of such defectiveness appear to be permanently incapable of receiving proper benefit from the instruction in ordinary schools.

Within recent years a considerable amount of work has been done upon the bio-chemistry of cholesterol, and valuable information has been acquired which has thrown light upon the important part which this substance plays in numerous physiological and pathological states. It will be of value in connection with the results described in this paper to shortly review some of the more outstanding facts which have been discovered.

In 1896 Kraepelin first introduced and defined his conception of the manic-depressive psychoses and dementia præcox. It has been fairly generally admitted that his was a brilliant piece of work, but since that time he has been led, in certain more or less minor respects, to modify his views. Briefly put, Kraepelin described in a very thorough and detailed way the symptomatology of these disorders, and then, according as the case was one of manic-depressive insanity or dementia præcox, the prognosis was held to be either good or bad respectively. Such a simple method of differentiation and of deciding on the prognosis seemed too good to be true, and although it must be admitted that in the main it holds good, yet in certain fundamental respects it fails. We all know that certain types of the manic-depressive psychosis do not get well, and on the other hand we all probably have seen cases which, symptomatologically, were cases of dementia præcox that recovered. In no group of cases has this been more clearly seen than in catatonia.