The institution of the new Diploma in Psychiatry by the Universities of Edinburgh, Durham, and Manchester, with the coincidence in my case of entering on my fiftieth year of membership of the Medico-Psychological Association—I find, alas! there are now only four names above those of Dr. Yellowlees and myself—has made a strong impression on my mind. The diploma seems the beginning of another stage of progress of our branch of science. We have in the half-century advanced all along the line, in our original research work—the core of the matter after all—in our literature, in our teaching, in our professional status, in our nursing, and in our salaries and pensions. The rate and amount of progress have been steady and considerable. Many of our younger men, I find, take that progress for granted. They scarcely realise the conservatism of the powers that be, medical and otherwise, in Great Britain, nor the former deep-rooted neglect of the public and of our profession towards anything connected with “Lunacy.” It is not, I am convinced, our administrative work nor our public usefulness alone that have helped us. It is the glamour which our science has lately cast on the public mind. Its inherent interest and its mystery have, almost more than anything else, aided our cause. I never yet had an audience of students in the class-room, or of ordinary citizens in the lecture-hall, or of the élite round a dinner-table whom I could not interest in the marvels of the human brain and the disturbances of its mental functions from the scientific point of view. The subject in its social relations is in the air at present. The man among us who fails to use this leverage for the ends of progress does not know his power. I have always cultivated an optimism in regard to the future of brain knowledge that has been unchanging and incurable. It seems to me that a retrospect and review of our position may be of interest to some of our workers. The new diploma gives me a chance of such a review.

Gentlemen,—My first duty, which is also a pleasure, is that of thanking you, as I do most warmly, for the honour you have conferred upon me in electing me to preside for a season over this great Association, a position which may well be called the blue ribbon of our department of medicine, rendered illustrious as it is by the names of great men who have held the office in the past. My only regret has been that in accepting it I replace one whom we should all gladly have seen in this chair, one whose enforced retirement cannot be alluded to without a feeling of loss, though we rejoice that his health is so far restored as to enable him to be amongst us to-day. For the rest, I am happy to echo the sentiment expressed by Dr. Macpherson a year ago, and to welcome my election as a token that the interests, aims and aspirations of the departments which preside over the lunacy administration of these countries are recognised as identical with those of all the other members of this Association—that, in fact, we all form one great body, united by devotion to as lofty an object as can animate the members of any merely human society.

Within recent years it has become a recognised practice to perform lumbar puncture on cases suffering from cerebro-spinal disease; the practical value of the procedure is generally admitted as an aid to diagnosis; and in some diseases, such as tetanus and cerebro-spinal meningitis, the operation is resorted to for therapeutic purposes. It must, however, be admitted that it is only in such diseases of the cerebro-spinal system as are due to the presence of well-recognised organisms that the diagnostic value of lumbar puncture approaches scientific accuracy, in such diseases, for example, as tubercular meningitis, cerebro-spinal fever, pneumococcal meningitis, and sleeping-sickness. The value to be attached to an examination of the fluid for the syphilitic reaction is minimised when one considers that for this test the blood-serum is preferable.

Melancholia is by far the commonest form of mental disorder that can be regarded as a true insanity, and from its general manageability is very often treated at home. A knowledge of it is therefore useful to the practising physician. There is another reason which increases the importance of this knowledge. Melancholia is always dangerous owing to the possibility of the patient taking his own life, and the presence of a tendency or desire to commit suicide is not sufficiently recognised by the members of the medical profession. It exists at one stage or another during the course of practically every case.

The case which forms the subject of this paper presents no rare or unusual features, being of quite an ordinary type such as one may meet with every day. Its relative freedom from complexity is the feature which makes it especially suitable for analysis. The delusional formation was strictly localised and showed no tendency to spread into other fields, and but for the one morbid theme the patient could be regarded as normal. It is from the less complex forms of mental disturbance that one may hope to obtain the most insight into the development of abnormal mental processes, and it is for this reason that the case which I am about to bring to your notice has been chosen for consideration.

We have ventured to bring forward the following case for various reasons. The first is the unusual distribution of the lesions found post-mortem, namely, in the supra-renal capsules and the pituitary body. The second is that during life the clinical features of the case were not sufficiently pronounced unmistakably to suggest any affection of the parts shown to be diseased at the necropsy. The third and most important consideration is that a narration of the facts raises the question of the significance of pathological changes in the ductless glands in the insane.

The sero-diagnosis of a syphilitic infection, commonly known as the “Wassermann reaction,” is based on the work published by Bordet in 1899, and Bordet and Gengou in 1901. It was there shown that the absence of hæmolysis could be made available as a naked-eye test indicative of a specific infection, and that the occurrence of hæmolysis negatived the existence of such infection. This reaction they showed was due to the fact that the anti-bodies produced by an infection were able to fix complement in the presence of the corresponding antigen, so that an attempt to complete an hæmolytic system after complement had been absorbed was ineffectual, and the homologous red blood-corpuscle remained intact, though exposed to the action of an inactivated homologous hæmolytic serum.

I feel that some kind of apology is due for my venturing to bring before a society which concerns itself mainly with practical questions what I fear will be regarded as a decidedly unpractical paper. Still, it may not be without advantage once in a way to step aside from the more arduous path of observational or experimental investigation in the region of psychiatry with its exacting conditions, and view things from a more general standpoint. And, while confessedly it may lead to no practical outcome, if by challenging some acknowledged views, and raising a breeze of controversy, however gentle, which may ruffle the quiescent surface of the pool of accepted opinion, it should at least suggest some grounds for a reconsideration of certain important questions connected with psychology and psychiatry, the object of the writer will be achieved.

The study of history, too often confined to the acquisition of bare records of facts and the mere recapitulation of actions, has more and more tended to widen its scope and to include in its purview the analysis of motives as an integral factor. It is true that the bald statement of events has an interest, and for some an overwhelming interest, whereto they confine themselves either by reason of intellectual inertia, or because compelled to restrict their wandering thoughts by reason of the powerful voice of authority; for others more intellectually alive or not subject to the same restrictions the conclusions do not suffice—the why and the wherefore must, if possible, be deduced. The keenly deductive type has been admirably delineated by Conan Doyle, and “Sherlock Holmes” may well stand as an example of those minds which urge their possessors inevitably to progress, so far as is humanly possible, to the unravelling of ultimate causes.

In discussing this theme before a scientific assembly it is needless for me to say that I make no claim to be the bearer of a new revelation, or the creator of a revolutionary therapeutic. My function is much more modest; it is to raise some questions that may lead to profitable argument, questions which have excited great attention in psychological circles in France, Germany and America, and yet which have scarcely stirred a ripple of interest amongst ourselves. Men of international reputation assure us that they have applied with singular success these psychical methods in the treatment of certain forms of mental disturbance, and our excellent English textbooks in psychiatry either ignore the whole subject or put the reader off with a few superficial remarks that afford no practical insight into the matter. Such men as Freud, Jung and Prince may publish their refined and delicate analyses and we continue to repeat our well-worn formulas, never dreaming for a moment that these men may have something to teach us. Their theories may be right or wrong, but their therapeutic successes are not open to question. Surely here, in Ireland, amid a population peculiarly amenable to psychic influence, it is for us of especial moment to learn how such influence may be exercised and by what methods it can be brought to bear upon disordered personalities. My purpose, then, is to make clear what these methods are, to indicate their strength and their weakness, and to show their bearing on mental hygiene.

For some time after the introduction of sulphonal, so highly appreciated was this new drug as a sedative, that every meeting of the Medico-Psychological Association resolved itself into a choir for singing its praises. It then seemed as if the qualities it possessed were ideal for calming the motor excitement of the insane. It was believed to be without danger, as very large doses had been taken suicidally or by misadventure without any more harm than unconsciousness lasting a day or two. As it was insoluble in ordinary media, it was tasteless, and it could be thus given to resistive patients without their knowledge. This property also made its action less evanescent than that of the other sedatives in use, and this was an advantage in the treatment of chronic excitement. Finally, by skilful dosage, one was able to exercise almost any degree of sedative effect, from the production of slight lethargy to almost complete paralysis. It was possible to tone down the restlessness of the simple maniac so mildly as to make life endurable to others living in the same apartment with him without any discomfort to himself. On the other hand, it was possible to paralyse voluntary movement so completely that the most excited patient became motionless and lay in a semi-stuporose state in bed, with little more than power to breathe and to swallow. If opium be entitled to the name of “the gift of God” in the eyes of orientals, from its power over pain and sensory disorder, eighteen years ago it seemed as just to apply this designation to sulphonal, by virtue of its action on motor excitement.

Recently, Browning, Cruickshank and McKenzie have described a new method of performing the Wassermann reaction. It depends on the fact that a syphilitic serum in the presence of an emulsion of lecithin plus cholesterin absorbs much more complement than in the presence of an equivalent amount of an emulsion of lecithin alone, whereas a negative serum absorbs equal amounts with both emulsions.

At this time and place it would be presumptuous of me and disrespectful to your knowledge and experience were I to claim any startling originality for this short paper.

In the following communication, it has been attempted to make a comparison between the opsonic indices obtained from the blood of the insane and those from the blood of normal individuals, and to draw the conclusion that in the case of those patients suffering from an abnormal mental condition we have a slight but nevertheless perceptible lowering of these opsonic indices. As only fifty-two cases have been examined, it is doubtful if one would be justified in drawing any definite conclusion from such small data.

In complying with the Honorary Secretary's request to read a short paper on some clinical or pathological cases, it occurred to me that it might be of some interest to the members to review a few instances of sudden death, or rather sudden and unexpected death, where the cause was unsuspected; in life, and in some instances left in doubt after post-mortem examination.

Medical science on the experimental side has been productive of no more interesting or fruitful results than those which have appeared in connection with the study of hæmolysis. The groundwork of this subject was laid by Bordet (1) in 1900 by the discovery of the fact that an immune serum contains a thermostable substance (immune body), which, in the presence of the original immunising agent (blood-corpuscles or bacteria), is capable of absorbing complement; that is to say, a hæmolytic or bacteriolytic serum heated to 57° C. for an hour will lose its power of lysing the homologous blood or organisms, but it will retain thermostable substances whose activity can be restored by the addition of fresh non-immune serum.

My excuse for reading to you a paper on asylum dysentery must be that, as the Commissioners in Lunacy state, “there is still a singular difficulty in affording a reasonable explanation of the exceptional prevalence of dysentery in asylums.”

It has long been known that in certain circumstances the dye-stuff indigo, or substances very nearly related to it, may appear as products of animal metabolism, and this fact has not failed to attract attention from physiologists, chemists and medical men. Indigo, in fact, possesses a “fatal gift of beauty,” which has always made it a focus of interest. Of no substance is the history easier to trace. In the earliest times it was obtained from the plant Isatis tinctoria, and served as dye and pigment under the name of woad, being no doubt a striking feature at meetings of the wild Silures in this locality some 2,000 years ago. More recently, during the past half century, the problem of the production of synthetic indigo has absorbed enormous sums of money and the energies of an army of chemists, and the successful competition which it now wages with the vegetable product forms one of the best instances of the return eventually obtained by those who cast their bread upon the waters, financing research in the hope of a return which they cannot definitely foresee.

Dr. J. S. Bolton has shown that in dementia the seat of greatest wasting of the cerebral cortex is commonly the prefrontal region, a region which (following Flechsig) he regards as a centre of higher association, the great development of which constitutes a leading character of the brain of man. This is a region which in man is one of the latest to myelinate (thirty-fifth in order, according to Flechsig), and if the order of myelination, as a part of ontogeny, may be taken as an approximate recapitulation of the order of phylogeny, then we might infer that the prefrontal region of man is a new region, of late development, absent or poorly developed in animals lower than man. Upon this assumption the predominant wasting of this region in dementia would be readily explained in accordance with Hughlings Jackson's doctrine of evolution and dissolution—dissolution following the inverse order of evolution. For an understanding of the pathology of insanity it is obviously important to inquire how far a study of comparative anatomy, especially of the primates, lends any support to such a conception. The aim of my discourse is accordingly to present, first, a brief survey of the recent observations of Dr. K. Brodmann, of Berlin, upon the comparative histology of the frontal cortex, and then some observations of my own upon naked-eye anatomy of the brain of man and higher apes.

The two subjects that I wish to bring to your notice to-day are sudden death during an epileptic fit, and the present treatment of confirmed epilepsy.