I often hear it said that pathological anatomy has proved a failure in the attempt to solve the problems of insanity.

Being personally satisfied by clinical observations that certain of the acute insanities are toxic in their ætiology, it occurred to me that it might be possible to demonstrate the presence of the toxæmia by means of the delicate test of complement-deviation. I argued that if a toxin existed in the blood, it would probably be excreted in the urine, and that at certain stages of the disease process a corresponding immune body would be found in the serum. In a series of observations carried out on these lines, I used urines as the antigen, and serum as the immune body.

It is sometimes cast up as a reproach to those engaged in psychiatry that zeal in research, and progress in knowledge in this subject have not kept pace with other departments of medicine, but I now describe some valuable additions to our knowledge which have all been made during the last decade on the diagnostic signs of general paralysis of the insane. Although the full title of this disease is a perpetual reminder of the fact that the credit of its discovery belongs to physicians engaged in asylum practice, it is desirable to drop the final qualification, and refer to it simply as general paralysis.

The wet pack was first systematically used by Lucas, an English physician, in 1850. His description of its use is on record prior to that of Freisnitz, the German hydrotherapist, to whom the credit attaching to its introduction has been generally ascribed.

“He, verily, did not hit the target of truth who took for his missile the phrase, the Desire for Existence; not the Desire for Existence— such is my teaching—no, the Wish for Power!”

The treatment of bacterial diseases by means of specific vaccines is a branch of therapeutics that has been steadily growing in importance in recent years. It is now being applied to every bacterial infective malady, from acne to acute septicæmia. Nevertheless, it is admittedly only at an early stage in its development. Every worker at the subject is still endeavouring by observation and experiment to improve its methods, to understand better its mode of operation, and to determine the extent of its useful application. It has already had brilliant triumphs, although, in common with other forms of medical treatment, it has to admit many failures. While it is now being extensively employed both in general and in hospital practice, it has not yet been utilised in our asylums as it deserves to be. The chief purpose of this paper is to endeavour to show some of the useful applications vaccine therapy may have in such institutions, and to encourage its employment.

For some years, we have been engaged in an investigation into the mode of action of toxins upon the central nervous system, and up to the present time have devoted our attention exclusively to the question of the upward passage of bacterial poisons along the sheaths of peripheral nerves to the spinal cord and brain. Experiment has shown us that toxins readily travel upwards in the perineural lymphatics, in which they induce an inflammation whose phenomena vary with the intensity of the irritant; and that this is continued without interruption to the central nervous system, granted that the toxins gain that level. Continuity of extension is, therefore, an important feature of lymphogenous inflammation, and is as constant in the central as in the peripheral nervous system.

Prior to the discovery of the Wassermann reaction it was practically impossible to obtain a correct estimate of the incidence of syphilis amongst the insane, owing to the infrequency of physical signs in specific cases, and the difficulty of obtaining reliable histories. Experience has shown that in a large number of cases a positive Wassermann reaction with the serum may be the only evidence of syphilitic infection; more over, Dr. Mott (Archives of Neurology and Psychiatry, vol. vi) has shown that definite skin lesions are comparatively rare in general paralysis of the insane.

It is quite likely with regard to the title of this paper that critics may say—

“Why cannot the writer say clearly what she is going to talk about? The words ‘early nervous and mental,’ cover so enormous an area,” or again “Why in any case should we of the Medico-Psychological Association be troubled with the word ‘nervous’ ; surely that pertains exclusively to the Neurological Society? Why should nerves—inferior spinal things—be mentioned in the august presence of those con cerned with the brain?” and yet there is no nerve of interest in the healthy human being which is not interdependent upon, or in close association with a brain. It is inconceivable that any nerve should suffer and leave the brain unaffected, if not from impressions sent up and down, then from absence of impres sions, and it is upon this vital essential oneness of the whole nervous system that I wish to lay stress to-day.

When, towards the end of August, your Secretary wrote and asked me to give you a paper to-day on villa asylums, I was just arranging to start on my holidays, and I hesitated at first to accept his invitation, as I saw little or no prospect of being able to give the time necessary for the preparation of a paper worthy of the occasion. But, on the other hand, feeling more or less the responsibilities of a parent, seeing that this institution was in a great measure the outcome of my advocacy of the villa system, I felt compelled to make a special effort and try and give you something which would at any rate form a basis for what I hope may form a useful and interesting discussion.

It is interesting at the present time to notice that disorders of the mind are being considered from a broader point of view. No longer is it reckoned sufficient to enumerate the psychic symptoms and to label the case accordingly. In the scientific journals it is not unusual to find the statement that a certain case does not fit into any division of our present-day classification. It is recognised that to describe a case as an atypical example of a disease is equivalent to saying that some factor has escaped our notice, or is one we cannot explain; that ætiology, from the psychogenic as well as the pathogenic point of view, must be considered, and that bodily and nervous symptoms may be as much a part of the illness as are the psychic; in fact, these last are often merely a symbol expressing some change in the function of an organ outside the brain.

In striking contrast to the elucidation of the cause and progress of various diseases by modern methods of examination, the phenomena of epilepsy, although long and widely studied, remain, to a very large extent, obscure. In recent years, however, some definite although dissociated facts have become known, and abiding views formed, from therapeutic and pathological data, and, within the last few years, from the investigation of the heredity of those afflicted. Although these facts may be comparatively few in number, it is surprising that no attempt is made even in the most recent text-book, to correlate such facts as are known and accepted, and to formulate a comprehensive theory which could be tested by experiment and further and independent observation.

The purpose of this article is rather to present a general review of the methods of intrathecal treatment of general paralysis, and the results obtained thereby, than to record our own limited and necessarily inconclusive experience.

Dr. Sidney Coupland, in opening the discussion, said: I need hardly say that I have read Dr. Gettings' paper with great interest, and have found it, as other readers must have done, very instructive as well as entertaining. What gives particular interest to his graphic story is the fact that it is based upon the continuous medical records of an institution for nearly a century, and in this respect it must surely be unique. From a remark in the paper, apparently more zeal in clinical note-taking was exhibited in the earlier than in the later period of the history of Wakefield Asylum, but I feel sure that, if this be so, the lapse can only be temporary. As regards dysentery, it is certainly remarkable that a disease, once fairly common in this country, should have almost entirely disappeared from the community at large, a disappearance which seems to have coincided with that of the last serious visitations of cholera in the middle of last century. Even if we accept the usual explanation that these diseases, like typhus, have been banished in consequence of wide-spread improvement in urban and rural sanitation, especially as regards drainage and water supply, we yet cannot ignore the fact that many an insanitary area still exists which à priori might be expected to favour the spread of such disorders. We know, too, how great a scourge dysentery has been to armies in the field, where conditions of fatigue, exposure, imperfect diet, as well as defective sanitation, favour the development of intestinal disorders. My own limited experience confirms the fact of the rarity of dysentery in the general population. During the past thirty or forty years the average number of cases of dysentery admitted into the wards of the Middlesex Hospital has not exceeded one per annum, and in the seven years (1873–9) that I worked in the post-mortem room I only had to examine two subjects of dysentery, one of whom had contracted the disease in India. I was therefore much surprised to find, on joining the Lunacy Commission, that almost daily notifications were received from asylums of deaths from “colitis,” mostly ulcerative in character, and clinically indistinguishable from dysentery, as had been well shown by Dr. Gemmel just about that time. Dr. Gemmel's monograph, published in 1898, was founded on his personal observations at Lancaster Asylum, where for some years “idiopathic ulcerative colitis” had prevailed. It would, therefore, seem as if dysentery, whilst dying out from the population at large, had found a habitat in asylums, whose inmates, owing to their careful segregation, were less liable to most of the zymotic diseases. Regarded as an infective disease, which Dr. Gettings holds to be a sufficient explanation of its persistence in asylums, one can well understand the difficulty in getting rid of it once it has gained a footing, owing to the conditions of asylum life, and the faulty habits of many of the inmates. But it is only of late that it has been so regarded, for it has been customary to ascribe its occurrence to bad sanitation, of which, indeed, colitis was almost considered to be an index. Such a view seemed to be supported by instances like those mentioned by Dr. Gettings in the Wakefield Asylum, of outbreaks of dysentery coinciding with grave sanitary defects, the removal of which was followed by the subsidence of the disease. A classical instance is that of the outbreak at the Cumberland and Westmorland Asylum in 1864, reported on by Dr. (now Sir) Thomas Clouston, then its medical superintendent. The outbreak, which was a severe one, and accompanied with a high mortality, was connected with the irrigation of fields adjoining the asylum with untreated sewage. Col. Kenneth Macleod referred to this epidemic in a discussion at the Epidemiological Society in 1901, and said that when he himself was assistant medical officer at the Durham Asylum in 1864 there was a similar outbreak of dysentery also, and, as at Garlands, it was associated with sewage irrigation. These and similar instances all lent support to the opinion that dysentery resembled enteric fever in being a “filth disease,” meriting as much as the latter the appellation of “pythogenic,” which Murchison applied to typhoid.

Progressive general paralysis is remarkable for the frequency, multiplicity, and variety of its pupillary symptoms, which may often be evident even in the incipient stage of the disease.

As the cases which come under notice in the present paper are of a somewhat miscellaneous character, and as, moreover, no one of them could, by the widest interpretation of the term, be described as insane, one feels a certain hesitancy in contributing them to a journal avowedly devoted to psychiatry. Though varying in type, they have this in common, however— that there was in every case an underlying or concomitant mental factor which afforded a clue to the case, and the most reliable indication for the line of treatment to be adopted. Briefly they belong to the category of the psychoneuroses, and in the main were treated on psychotherapeutic lines. No uniform method was adopted, waking suggestion, persuasion, hypnosis, or the induction of a hypnoid state being utilised, separately or in combination, according to the exigencies of the particular case. Where necessary, it was supplemented by medicinal and general hygienic measures, but except in one case there was no attempt at psycho-analysis in the accepted sense. In most of the cases an attempt was made to induce hypnosis, but in Cases 3 and 6 it was only possible to attain what is called by American writers the hypnoidal or sub-waking state. In this state, according to Sidis (1), “Emotional excitement subsides, voluntary activity is changed to passivity, and suggestions meet with little resistance. The sub-waking state is above all a rest state, a state of physical and mental relaxation.” The utmost that was obtainable in these cases was a condition of passivity, and of cessation from voluntary activity, in which there was increased susceptibility to suggestion, and which lacked many of the characteristic phenomena of true hypnosis. Whether this is merely a mild degree of hypnosis, or a condition sui generis, as Sidis contends, is not practically important, though in favour of the latter view it is to be noted that it is difficult to pass from it into true hypnosis even after many sittings. Nor is there the tendency to attain deeper stages of “sleep,” which characterises the genuine hypnotic state. Apart from the increased suggestibility, the mere state of quiescence and tranquillity (which can be maintained for an indefinite period) affords a valuable means of nerve recuperation where psychomotor unrest and anxiety are prominent symptoms. Thus it is particularly useful in typical neurasthenia, mild degrees of melancholia, and conditions in which the nervous energy is depleted, and where physiological rest is the primary requisite.

The problem of leucocytosis has been the subject of much discussion in recent years. Amongst the earlier workers on the subject Virchow stands prominent, and he first gave the name of leucocytosis to a temporary increase in the number of leucocytes in the blood, this occurring both in physiological and pathological conditions. During the past twenty years special attention has been paid to this phenomenon, bringing to light some very important information. Amongst later workers Metchnikoff has done more to enlighten us as to the problem than any other worker. To briefly recapitulate his doctrine. The leucocytes protect the organism against harmful germs by catching them up in their pseudopods, by investing them, and thus robbing them of the possibility of exerting their deleterious action externally. The termination of an infective process would therefore depend alone on whether leucocytes possessing this function are present in the blood in sufficient numbers to overcome the invasion of the germs. The doctrine of Metchnikoff has been modified and also extended by other workers, notably Denys, Löwy, and Richter, who have proved that the value of the leucocytes does not depend on their pseudopods, but that their chemical products yield the strongest protection to the organism. The leucocytes are able by means of the bactericidal or antitoxic substances which they give off to paralyse the toxins produced by the bacteria, and in this way render the microbes harmless by depriving them of the weapons of attack, even if they cannot destroy them.

Last year a paper was given by one of us on the history of dysentery at Wakefield Asylum since its opening in 1818(a), and it was shown that all the evidence pointed to carriers and chronic cases as being responsible for its presence, persistence, and perpetuation there. After an epidemic period they kept the infection alive, and gave rise to the sporadic cases which always occurred in the inter-epidemic times.

Under the heading of “katatonia” are included certain peculiar states of stupor and excitement, which tend to alternate irregularly with one another. Thestuporose phase is characterised by increased muscular tension, or in some instances catalepsy, together with negativism, mutism, refusal of food, contrary acts, or not infrequently an increased suggestibility, as shown by echolalia or echopraxia. The prominent features of katatonic excitement are increased psycho-motor activity, attitudinizing, stereotyped movements and phrases, verbigeration, and senseless impulses. Various forms of convulsive attacks are motor phenomena which frequently occur during the course of the psychosis.