In view of the impending meetings of the Fourth International Congress on the Care of the Insane, to be held in Berlin from October 3rd to 7th, 1910, it seems desirable that the members of the Medico-Psychological Association and other readers of the Journal of Mental Science should be able to have in print a record to the present date of the proceedings of the International Committee, which was originally appointed at the Congress held at Milan in 1906 with the object of studying the causes and prophylaxis of mental disease.

As long ago as 1901 my attention was called to the therapeutic value of electricity administered through the medium of warm water in a bath by my friend Dr. Lewis Jones, Physician in Charge of the Electrical Department, St. Bartholomew's Hospital, London. He considers this is the best means of employing electricity for general therapeutic purposes, describing it in his work on medical electricity as a method of great value whenever general stimulating and tonic effects are required. In this work will also be found reference to the treatment, some years since, of eighteen males and five females at Claybury Asylum by Dr. Robert Jones, with results which he considered satisfactory. In these induction coil currents were used in the bath. The method appeared to me likely to prove much more convenient and practical than the usual methods of faradism and galvanism, which do not lend themselves to the purposes of general as apart from special and local application. Largely, I think, for the lack of a convenient method of general application, electrical treatment has been almost discarded, at any rate in this country, in mental diseases. I hope in this communication to show that this therapeutic means is one which should not be neglected.

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

It is with considerable diffidence that I bring this subject before such an Association as this. I should have the same feeling were I to argue before the Mathematical Society for the merits of the Multiplication Table, or before the Astronomical Society in favour of the Law of Gravitation. It is a matter that I have regarded as an axiom for the last five and twenty years, and that I fondly thought was established as a fundamental doctrine of alienism. My astonishment was great therefore, when, at a recent meeting of the Education Committee of this Association, my proposal, that the doctrine should find expression in the syllabus of subjects for the diploma in Psychiatry did not find a single supporter. The experience carried me back to the early years of my membership of this Association, when I constantly found myself in a minority of one in advocating views which are now become commonplaces. It seems, therefore, necessary to bring the matter formally before you, and to argue it out; and here I am in the difficulty felt by everyone who tries to prove formally what seems to him self-evident. I believe that things that are equal to the same thing are equal to one another. I do not know whether any of the members present share this belief. If they believe that conduct is of no importance in insanity, the same cast of mind may very well cause them to believe that things that are equal to the same thing are greater than one another, or that two straight lines can enclose a space, or that things that are unsupported fly upwards. But if they do believe that things that are equal to the same thing are equal to one another, they would have considerable difficulty in giving a reason for the faith that is in them. If I question the truth of it, and ask what are the grounds of their belief, I think I should place them in a quandary. I am in a similar quandary in demonstrating that disorder of Conduct is the prime element in Insanity.

There are certain persons who, having taken alcohol to excess, develop a form of insanity characterised by distinctive features, clinical and pathological. [This is the form which I mean by “alcoholic insanity.”]

The following observations are founded upon the records of 301 autopsies performed by myself at Rainhill Asylum. They are concerned principally with certain abnormal and morbid manifestations which occur within the crania of the insane. Of these the chief are, on the one hand, indications of subevolution, as shown by macroscopic structural defects of the cerebral hemispheres, such as deficiency of weight or of convolutional complexity, and on the other, evidence of dissolution as exhibited by wasting of the cerebral hemispheres. The relationship existing between these abnormal and morbid manifestations and certain other intracranial appearances is also discussed. No attempt, however, has been made—for reasons which will afterwards be given—at any close correlation between these abnormal and morbid manifestations and the mental states recorded during life. The observations, therefore, are of a pathological rather than a clinical nature.

From the earliest ages in the history of man, we find evidences of the existence of beings stunted in body and defective in mind, whose relations with their fellows varied through the centuries. At one epoch they were exalted almost to the level of a deity, and their symptoms were interpreted as manifestations of Divine will. At another they were looked upon with loathing and disgust, not unmingled with fear. Still later, they were either the playthings of kings or the victims of cruel jibe and blow, and their existence at the present day, and the associated conditions of insanity, crime and intemperance, constitute one of the most serious, if not the most serious problem which a civilised community is called upon to solve.

Mr. President and Gentlemen,—I have had a little difficulty with my title, because the disease to which I want to refer is known under so many names. “Exhaustion psychosis” is one, and the same disease is also described as “post-febrile insanity,” “acute confusional insanity” and “acute hallucinatory insanity”; while on the Continent, I think, psychiatrists are unanimous in applying to it the name “amentia.” But “amentia” in this country has a different meaning, so that we cannot adopt that term here. Having, however, given you the list of names by which the condition is known, you will recognise the disease to which I refer.

One of the most obvious impediments to the advance of our knowledge of mental diseases is the lack of a physical basis of classification. This deficiency is constantly presenting itself, and even in such a comparatively simple disease as mania one is often in doubt as to whether the diagnosis should be manic-depressive insanity or confusional mania.

Surveying insanity as a whole, one recognises as a fundamental fact that insane persons belong to a class who start life with a “deficient grade of organisation” of the nervous system called “hereditary predisposition.” Some authorities hold that this is the sine quâ non of insanity, but such a view, I consider, is not strictly accurate. It is certainly not borne out by statistics. All observers, using even indifferent discrimination, must have noticed cases in which no hereditary factor could be traced, but in which much self-abuse had occurred—either in the form of alcoholic, sexual, and other excesses—or where syphilis or other powerful toxæmic conditions had been contracted. Such conditions, I argue, may themselves break down the most hardy constitution and leave it a prey to secondary infections or intoxications, which may manifest themselves as insanity. Assuming that the insane, prior to their attack of mental disease, suffer from either some hereditary weakness, or some acquired constitutional degeneration, it is most probable that such defects act a dual part, weakening not only the nervous system, so that it is more susceptible to the actions of toxins and environments, but also weakening the natural defences of the body. The nervous system of these people is thus laid open to more severe and frequent attacks from poisonous substances, whether of bacterial, metabolic, or other sources, than is the nervous system of a more normally organised individual. In support of this statement I would mention that Dr. L. C. Bruce has pointed out that over 60 per cent. of maniacal patients were deficient in the normal protective agglutinin to certain strains of Staphylococcus aureus. This agglutinin is always present in healthy sera. Further, Dr. C. J. Shaw has ably demonstrated that the reason tubercular diseases account for so large a proportion of the deaths in asylums lies, not in any faulty hygienic precautions, but in the fact that the resistive power of the insane to tubercular infection is below par. Assuming that this hypothesis is true, we can more readily understand why the various insanities so frequently resist our efforts to cure them.

In previous papers it has been contended by Dr. Douglas McRae, Dr. Dods Brown and myself, that in cases of general paralysis there are special bacterial infective foci in the nasopharyngeal and buccal mucous membranes, and that these infective foci are of importance in the pathogenesis of the disease; Dr. McRae and I have also maintained that in cases of tabes dorsalis there are similar infective foci in the genito-urinary tract. In this paper I wish to deal with some further investigations, the results of which give additional support to these views. In the fifteen minutes at my disposal it is impossible for me to describe these investigations in detail. I can only indicate their chief results and state some of the conclusions that they seem to me to warrant. All the evidence that I can lay before the meeting is shown under the ten microscopes on the tables.

In May, 1907, we published the results of our first series of experiments dealing with the question of toxic absorption along the lymphatic paths of nerves and the effects upon the spinal cord, medulla, and pons.

Melancholia, with its attendant constipation and faulty alimentation, lends itself at once to a dietetic form of treatment.

Whether the constipation is dependent on defective innervation and is a direct symptom of melancholia or is the initial cause of this mental disturbance, it matters not so far as our endeavours in treatment are concerned.

The subject of lunacy administration in our Colonies, and in other countries, is one not so well known as it should be to those of us who are specially interested in these matters in this country, and I was pleased to see recently articles in our Journal by Drs. Eric Sinclair and Beattie Smith treating of this subject as found in Australia. If our Editors published a series of articles referring to lunacy administration, as met with in our Colonies and foreign countries, these might prove useful when our own Lunacy Act undergoes amendment.

From the earliest times in the history of medicine probably no subject has been more thought about, no subject more frequently attacked, than that of heredity, and it is therefore not without a certain amount of hesitation that that all-important subject is brought into consideration in such an article as this.

The very interesting publications by Dr. Ford Robertson and his pupils on the discovery of a bacillus as the cause of general paralysis of the insane have given rise to the following research.

A Granular condition of the ventricular ependyma, especially that of the fourth ventricle, has long been recognised as one of the most important of the post-mortem lesions of general paralysis. In the opinion of the writer it is present in at least 90 per cent. of the cases, and the more carefully the examination of the ependyma is made, the greater will be the percentage of cases showing granulation in asylum post-mortem books. In the Journal of Mental Science, July, 1905, the writer recorded the frequency of this condition in an analysis of 131 consecutive post-mortems on male paralytics at Wakefield Asylum, and on 112 male and 19 female cases at Horton Asylum. The percentages were 878, 90, and 100 respectively. Blatchford (Journal of Mental Science, 1903, p. 483) states 70 per cent. of paralytics were recorded as exhibiting granular ependyma, and of the non-paralytic deaths 16·6 per cent. of men and 5·3 per cent. of women. There were 83 paralytic deaths and 369 non-paralytic. The writer is convinced that granularity of the ependyma, especially that of the fourth ventricle, is the most valuable naked-eye diagnostic sign of general paralysis. This statement is supported by that of Bolton, who considers the most characteristic naked-eye sign of dementia paralytica to be granularity of the ventricular ependyma, referring specially to the lower half of the fourth ventricle.

The present paper endeavours to describe, in a short and summary form, the principal tenets of the school of psychology founded by Professor Freud, of Vienna.