Much work has been done within recent years towards elucidating the causation of mental diseases, and it is now recognised by most alienists that some forms of mental disorder are due to toxins, many of which are microbic in origin. At the same time there does not seem to be any general agreement that one particular organism or group of organisms is the exciting cause in any particular disease.

In 1893 one of us published an account of an unusual condition of the scalp. He believed that the abnormality had not previously been described. In this opinion, however, he was mistaken, for as far back as 1884 Poggi had recorded a case. Since attention was first directed to the matter a few writers, English and foreign, have published cases and ventured on various but conflicting opinions in explanation of the facts observed. The last known contributor is Dr. Eugenio Bravetta, who communicated a paper to the Medico-Chirurgical Society of Pavia in 1910. It contains an account of three typical examples, and is useful in giving a list of published cases with their authors; but it is specially valuable because it epitomises the views of the various writers. As this communication of Dr. Bravetta is in Italian, a language not read by the majority of us, we venture to give, by way of introduction, a free translation and abstract.

Gentlemen, According to promise, I shall give you a short paper on a subject which at first sight may not seem to have a very practical value, but I hope to be able to show you that the land of dreams may provide something both of interest to the physician and to the philosopher.

The questions I particularly desire to raise in order to ascertain the opinion of my fellow-members are three: (1) the actual meaning of the technical term “dementia” and the variety or varieties seen or met with as primary conditions; (2) the amount of “mental weakness” which this term connotes, i.e., that exists compatible with responsibility or liability to punishment; and (3) the question whether there can exist such a condition as partial against complete insanity, and, therefore, also partial as contrasted with complete responsibility.

The history of the use of thyroid extract in insanity dates back to the year 1893, when McPherson (1), of Larbert Asylum, reported a case of myxódematous insanity which recovered from both the myxódema and the mental disorder under its use. Its use in cretinism has also met with much success. My investigations, however, are confined to its use in mental conditions not associated with myxódema or cretinism. In 1894 McClaughey (2), of the District Asylum, Maryborough, reported two cases as improved, and in 1894–5 McPhail and Brace's results (3) and observations of treatment were published in detail. The publication of their results and their belief that “in thyroid feeding we possess a valuable addition to our armamentarium in the treatment of certain cases of insanity” incited many other alienists to test its efficacy. Besides Clarke, Brush and Burges in America must be mentioned Mabon and Babcock (4), who give a review of the results obtained in 1032 collected cases of insanity from twenty-four different observers, and who show that 23·9 per cent. recovered and 29·4 per cent. were improved. They also report on a further use of thyroid on sixty-one cases at the St. Lawrence State Hospital.

If there is one fact which stands out more plainly than any other when one considers the life and work of Emanuel Swedenborg it is this—that whatever value may be attached to the writings of the later or visionary period of his life, there is no doubt they have served to obscure his eminence as a clear-sighted scientific investigator during the earlier part of his existence. That this is so can hardly be denied even by the most enthusiastic Swedenborgian, for if the average person be asked what associations the name of Swedenborg conjures up, he will at once reply that he was a man who saw visions and dreamed dreams, who said that he saw the heavens opened unto him, and who wrote an account of the same in a work entitled Heaven and Hell. A further effort of association will perchance link his name with those of Jacob Boehme, of St. Theresa, of Mahomet, and of others who have exhibited similar symptoms; but, except in rare instances, any conception of his scientific attainments even in the most meagre degree is almost non-existent. He is passed over practically without comment by most of the historians of philosophy or of psychology; and his fate has for the most part been to suffer from the uncritical eulogies of enthusiastic disciples, or from the criticism of those whose knowledge of him is limited to the later period of his life with which his mystical writings are associated. In both cases he has suffered—and the term is used advisedly even in the first instance—because scientific men have been repelled from studying one whom they have conceived as immersed in the business of describing visions of the hereafter and consequently as hardly being likely to have given much time to the concrete realities with which science should deal. Most of the discussions as to Swedenborg's place in the history of thought have centred round the later period of his life; and the mental trouble which came upon him in the midst of his scientific activities and altered the whole course of his intellectual career, sore affliction as it was during his lifetime, has not yet ceased to cling to his name, and to militate against his recognition as one of the clearest thinkers of his time, or indeed of any time. Rational psychology owes a great debt to him; like many debts it has remained long unpaid. This, too, whilst many an inferior thinker has had his wares cried in the market-place, making of real obscurity an appearance of profoundity. It is not proposed herein to deal with Swedenborg in a more comprehensive way than as a psychologist; to do more would necessitate such an acquaintance with science and with technology as but few possess. For it was Swedenborg who “introduced the calculus into Sweden. … He began the science of crystallography. He reasoned out before Franklin the identity of lightning and electricity. He anticipated Laplace in the discovery that planets and planetary motion are derived from the sun. He discovered the animation of the brain. The law of the conservation of energy seems to have been anticipated in his doctrine of action and reaction equal and necessary to life.” So says a writer in a recent authoritative work (1); and even if the claims be debatable, it is obvious than any discussion of them would but serve to obscure our more immediate purpose, which is to deal with Swedenborg as an exponent of psychology.

In bringing forward some evidence which would point to the biological course followed by some forms of nervous disease to be considered, I would first of all accept as a working hypothesis two generalisations which apply to all forms of disease. The first of these generalisations is that there is essentially no difference in kind between a physiological and a pathological process. The distinction is an arbitrary one; the course of disease is distinguished from that of health only in so far as it tends to compromise the continuation of a more or less perfect adaptation between the organism and its surroundings. There is no tendency in Nature either to kill or to cure; she is absolutely impartial as to the result of a conflict between organisms and a host; and it is a matter of complete indifference to her as to whether toxins are eliminated or not. In the same way diseases of the mind are the manifestation of a perfectly natural relation of the organism, such as it is, to the environment. If the mental processes are abnormal, it goes without saying that the brain must be acting abnormally whether the stimuli to abnormal action originate in the brain itself or in some other part of the body. For example, if a child with pneumonia be suffering from delirium and hallucinations, as is not infrequently the case, this must be considered a perfectly natural outcome of the relation of the brain to its environmental stimuli outside and inside the organism. The actual stimuli may originate in the intestine from masses of undigested food and the stimuli may play on the brain rendered hypersensitive by the toxins from the lungs; the process and its manifestations, as well as the final outcome, are matters in which nature plays an impartial part. It cannot be admitted that there is any form of nervous disease which does not come under this generalisation. It has been argued by some authorities that because insidious forms of insanity are marked only by the slightest variation from the normal course of mental life, and that because the mental abnormalities are only modifications, and often easily explainable modifications, of normal mental processes, that the so-called insanity originates in these processes, and not in the material substratum of the organism. The fallacy of such an interpretation is obvious; it is tantamount to saying that slight albuminuria is the cause underlying early disease of the kidneys, or that a slight ódema may have something to do with the origin of circulatory disease. It is only natural that in the milder forms of mental disease the abnormal manifestations of brain activity should resemble normal mental processes; and even in the most advanced forms of mental disease there must be a close resemblance between abnormal ideation and conduct and perfectly normal ideation and behaviour. Even in advanced cases of Bright's disease the urinary elimination is more normal than abnormal; the abnormal constituents do not differ so much in kind as in degree from those of urine from healthy kidneys. It is not to be expected that in kidney disease bile or some other substance foreign to the organ would be the chief constituent of the eliminated fluid. The signs of insanity in any given case are the natural products of normal brain action mingled with the products of abnormal action. This does not, of course, preclude the possibility that under certain circumstances these abnormal products, such as delusions, hallucinations and perverted conduct, may not themselves be the direct stimuli to further abnormalities. The suicidal character of pathological processes is well seen in other organs of the body. A diseased heart, for example, is its own worst enemy; it not only fails to supply sufficient nutrition to the rest of the organism, but it starves itself by its inability to contract and expand properly, thereby increasing its own weakness. In the same way, certain phenomena of abnormal brain processes are in all probability due to the recoil on the brain of its own abnormal products in the matter of ideation and conduct.

The question of how far insanity can be pleaded in extenuation of, or as an explanation for, the committal of an indictable offence is one that possesses for me unusual interest.

The following case presents some important features from a diagnostic point of view, owing to its unusual onset and course, and the relative absence of initial symptoms indicative of the actual character of the psychosis.

A distinguished Dutch neurologist, crossing the ocean recently, was asked to state the object of his visit to America. “I am bent on study,” he answered. “I wish to study nervous diseases among the most nervous people on earth.” Waiving the fact that nervousness and mental disease in America are to an overwhelming degree found among the foreign born element, and cannot, therefore, be truly attributed to American environment and influences, the allegation that America is a ripe field for the study of nervous disease must be acknowledged. Everywhere throughout the country attention is being called to the alarming increase in insanity in the past decade. Without doubt such disturbing reports take far too little count of the effect upon statistics of the wonderful advance in later times in accuracy of recognition and registration of insanity, and of the constantly increasing tendency to house, restrain and treat the subjects of mental disease.

In a Paris restaurant on January 2nd, 1911, an alcoholic shot and killed, without provocation, a peaceful diner. Dr. Vallon, the medical expert, concluded that the accused, who had a family history of insanity, was a congenital deséquilibré, a chronic inebriate addicted to alcohol and ether; that the murder had been committed in a state of intoxication, and had been forgotten by the prisoner; that he was not insane, and was criminally responsible; that, nevertheless, in consideration of his hereditary and acquired predisposition he might be considered as having been in a state of pathological inebriation at the time when the act alleged against him was committed; and that in consequence his responsibility was modified. The trial took place on August 3rd, and the accused was acquitted and discharged; but the members of the jury in a letter to the Ministre de la Justice represented that criminals acquitted as irresponsible, remained a danger to the public safety, and earnestly requested that the competent authority should send such persons to custody in a specially constituted establishment, to be detained until it should be duly certified that they were no longer dangerous.

The most important event in the department of psychiatry in Germany since my report in 1910 has been the Fourth International Congress for the Care of the Insane, which was held at the house of the Prussian Deputies in Berlin, from October 3rd till the 7th, 1910. The Congress was attended by about six hundred members. It compared favourably with its predecessors in the number and practical and scientific importance of the reports and in its general arrangements; it was evident that the interest of psychiatrists and of laymen in those congresses is on the increase. In addition to the meetings of the members, there was an important exhibition of models, plans and photographs of establishments and institutions for the insane, of sick-rooms and of machinery, of work done by patients in public and private institutions, and of scientific apparatus and books, which was visited with great interest, and which gave a very true idea of the progress in Germany in the care of the insane. The exhibition had been arranged by Dr. Alt, at Uchtspringe (Altmark). A no less true insight into German methods is given by a work on German Hospitals, which was edited by Dr. Bresler. A copy of this work was presented as a souvenir to each member of the Congress. It was edited with the assistance of the superintendents of the public and private asylums, and contains in an elegant volume of 666 pages the description of about seventy institutions for the insane, illustrated with numerous plans and photographs. This work has since been continued, and a second volume of 465 pages, with illustrations, has recently appeared. At the same time a similar work has been edited by Dr. Schloess, of Vienna, on Austrian asylums for the insane, copies of which (and of the second volume of the above-mentioned work) were also presented to the members of the Berlin Congress. So that it may be truly said that seldom have members returned from a congress with so abundant a supply of literature. A special number of my Weekly Journal of Psychiatry and Neurology was devoted to the members of the Congress, and contained about fifty portraits with short biographical sketches of the most distinguished alienists present. The more important papers are perhaps worthy of mention in this retrospect.

From April 1st to the 7th this year the Twenty-second Annual Congress of Alienists and Neurologists of France and of French-speaking countries, consisting of a membership of about 300 adherents, was held in Tunis, and the writer attended as a delegate of the Medico-Psychological Association of Great Britain and Ireland. More than thirty institutions for the care and treatment of mental cases were associated with the Congress, and numerous delegates representing learned societies as well as foreign countries attended. The President of this year's Congress was Dr. Mabille, Medical Superintendent of the La Fond Asylum at La Rochelle; Dr. Arnaud, Physician to the Mental Hospital of Vanves (Seine) was Vice-President; and the General Secretary was Dr. Porot, the very able and energetic Physician to the French Hospital in Tunis. An important paper announced for discussion was by Dr. Régis, Professor of Clinical Psychiatry in the Faculty of Medicine at the University of Bordeaux, who contributed a very full and exhaustive paper upon the “Care of the Insane in the French Colonies and Dependencies,” with a review of their treatment in the adjoining colonies such as those of England and of Holland. Dr. Régis was assisted in his paper by Dr. Reboul, of Annam. Another paper was by Dr. Chavigny, Major of the French Army Medical Service, upon the “Mental and Nervous Symptoms associated with Malaria”— obviously one of considerable importance in view of the expansion of French Colonial Government; and a third paper by Dr. Dupré, one of the teachers and a Fellow of the University of Paris, was upon mental states arising from, and connected with, perversions of the natural instincts. Although these were the three main subjects, other papers connected with neurology or psychiatry were presented to the Congress for discussion, among them being—one upon “Goitrous Insanity” by Drs. Fraikin and Grenier de Cardenal, one relating to “Insanity and Renal Disease” by Dr. Beriel, one by Dr. Gelma on “Delusions of Persecution.” Other papers were by Drs. Petit, Mignot, Adam and Levassort. A valuable report upon an experimental study relating to the association of ideas in the Insane was presented jointly by Dr. Auguste Ley, Professor in the University of Brussels, also physician to the Mental Sanatorium at Fort-Jaco, Uccle, near Brussels, and Dr. Paul Menzerath of the same hospital laboratory. Another paper was by Dr. Levassort upon “Degeneracy in its Relation to Perverted Instincts,” and two others bore upon the same subject, viz., one by Dr. Berillon, relating to the influence of suggestion upon normal as contrasted with abnormal instincts, and the other by Dr. Simonin who related his experience in the French Army in regard to mental enfeeblement, a clinical and medico-legal study. A paper by Dr. Haury upon “Hooligans in the Army and their Rational Treatment,” formed a suitable complement to the chief paper of the day by Dr. Dupré.