General paralysis is common in our large cities, and assumes so many disguises that it is necessary to be ever on the alert for it. About a third of the male admissions to asylums between the ages of thirty-five and fifty suffer from it, and the possibility of its presence should always be remembered in the case of a man of this age presenting mental symptoms. Such men are usually the heads of families, and occupy positions of responsibility, for as a rule those who suffer from general paralysis are no weaklings. The social troubles and inconvenience produced by the occurrence of adolescent or senile insanity, bad as they may seem, are therefore trivial compared with those produced by a disease such as this, which attacks the bread-winner of a family and the head of a business in the prime of his life.

The command laid upon mankind to increase and multiply on earth has been gladly obeyed and abundantly fulfilled. In parts thereof the multiplication has sometimes gone beyond the means of subsistence, and the unoccupied parts suitable for human habitation become scarcer, though there are yet vast areas of undeveloped land in the South American Continent. Nevertheless the race continues to multiply without regard to the possible risk that it may one day outgrow its means of subsistence, increase of population and increase of trade being the ideals which it is thought right to pursue in order to maintain and increase the health, wealth, and prosperity of the nation in particular and of the race in general. The more babies that are born and reared in a country, the more bargains that are made in it, the more wants and their gratifications are multiplied, the sounder is its strength and the brighter its future outlook, although it is not unimaginable that fewer children, fewer wants, fewer bargains might sometimes produce more health, more virtue, more progress, more stability. That, however, is an unbecoming suspicion to harbour, for it is unworthy the trust which it behoves a right-thinking mind to put in the providential scheme of the universe and its benevolent workings for human ends. Impotent to comprehend the mystery of things, foolish to expect it, fatuous to bewail his inability to get behind the veil, which would be to get absolutely out of his relative self, man is yet sure that the universe was created and works for his advantage and perfecting, and in that happy faith counts an unlimited procreation in gratification of a natural lust his proper and pleasing duty. The instinct of human nature dictates it, therefore the laws of universal nature were framed to sanctify it.

Since experimental observation has established the fact that inflammation of the central nervous system is easily induced by infection of the ascending lymph stream of nerves, it would seem that the views regarding the ætiology of inflammatory lesions of the cerebro-spinal axis must undergo considerable revision, and that an insufficient degree of importance has so far been attributed to the rôle and wide-reaching results of lymphogenous infection. That the spinal cord and brain are exposed to infection along this path cannot be doubted. This view is based upon both clinical and experimental data; and its value in connection with the elucidation of the ætiology of some nervous lesions may now receive more recognition, seeing that the range of application of the hæmatogenous theory is becoming more limited. To take one example: acute anterior poliomyelitis is no longer regarded by neurologists as a hæmatogenous infection of the spinal cord, with a special selectivity for the motor nuclei. Recent work shows conclusively that the inflammatory phenomena can only be the result of a lymphogenous infection.

Ladies and Gentlemen,—I thank you unaffectedly for the great, and, I feel, undeserved honour that you have done me in making choice of your President for the coming year.

In spite of attempts at classification, most observers will agree that the disease known as neurasthenia has no definite boundary line. However strict an attempt is made to define its limitations, everyone who has to do with these cases must admit that the symptoms frequently merge into those associated with other conditions, such as those known as psychasthenia, melancholia, hypochondriasis, anxiety neuroses, obsessions and others. Even hysteria in its less pronounced forms is not always easy to separate from neurasthenia, and in not a few instances some of the salient features of both diseases may be present at the same time, and that this close association is recognised is shown by arguments that have occasionally been put forward for placing the disease known as traumatic neurasthenia into the category of traumatic hysteria. All classification is artificial and provisional, but useful and necessary as it is for studying the general group aspects of disease, there is the danger of over-estimating its importance, and of being tempted to feel the necessity of labelling a disease and then treating it according to such rules as are applicable to the label which has been placed upon it.

A considerable number of men are received annually into Brixton prison remanded, or committed for trial, on a charge of attempted suicide. They are all specially examined as to their mental condition, and a large number of them are remanded for that purpose. From the plentiful clinical material thus studied these remarks were prepared whilst I was on the medical staff of that prison, and I have to thank the Prison Commissioners for their permission to publish them.

Gentlemen,—I welcome you to this the first meeting of the first new Section of the Royal Society of Medicine. I have consented to give an inaugural address, somewhat against my feelings, for I believe that as this Section is one starting with the full intention of work for the advance of medical science, time might have been better occupied in learning definite results of original work than in hearing generalities. I have to admit that I have had very long and perhaps exceptional opportunities of observing mental disorders, and it may be of service to record some of my impressions and hopes. I will shortly outline the past, survey the present, and prospect the future.

The title of this brief paper will be familiar to many of you as the heading to letters which have recently appeared in several successive numbers of the British Medical Journal. Some of the letters have been signed with the full name of the writers, others with a pen name. They have all been characterised by moderation of language in the presentation of the case in which the writers and many others are deeply interested. For some time past I have felt strongly that something should be done to improve the position of assistant medical officers of asylums, and am in full accord with the work of the Committee of this Association, who have recently furnished an interim report upon this subject. A further report will doubtless soon be forthcoming upon the financial and social position of assistant medical officers, and it is this view of the case which I desire to place very briefly before you this afternoon.

At the present time when the Mental Deficiency Bill is before Parliament a discussion on the above subject may be of some interest to the readers of the Journal of Mental Science.

I feel that some apology is needed from me for venturing to introduce for your consideration a subject which, however important from the standpoint of the national health, bears but little relation to the deeper scientific problems usually discussed at the meetings of this Association. I can only urge in excuse for my temerity the desirability of calling attention to the changes recently introduced in the registration of deaths with the object of obtaining greater uniformity in tabulation and consequently greater accuracy in vital statistics. The matter concerns every registered medical practitioner, whose statutory duty it is to furnish the information on which the Registrar-General builds up his instructive tables, and all must appreciate the endeavour to secure the object referred to. In asylums for the insane, where the death-rate is relatively very high, there is ample opportunity for supplying precise information, especially as in three out of four cases the cause of death is verified by post-mortem examination, thereby enhancing the reliability of the returns.

The occurrence of micro-organisms in the urine is well known to be associated with a variety of pathological conditions, among which mental diseases have been included. A definite connection between urinary bacteria and insanity, however, does not seem to have been made out, the subject being even more obscure than the relation of the intestinal flora to mental disease, which has been much more frequently investigated.

In the United States of America each state has self-government and different laws, and the latter differ to an even greater extent than is the case between the laws of Scotland and England; consequently some states have progressed infinitely further than others in the laws and the application of these laws for the social welfare of the people.

Except in asylums, dysentery in this country is a rare disease to-day. Yet it was once far otherwise, and to our ancestors the “bloody flux” was a household word. It was endemic here from the earliest times, and as we follow it down we find that it always presents the same characteristics of bursting out in an epidemic form at fairly regular intervals, then dying down to isolated cases for a longer period until the cycle was complete for the next outbreak. It was only in the latter half of the nineteenth century that it vanished from our midst, and so complete has been its departure that it has also disappeared from our memories, and to-day we have forgotten what a virulent pestilence it once was.

In dealing with any subject in connection with the burning question of the care and control of the feeble-minded, some reference will be expected to the second Mental Deficiency Bill recently introduced into the House of Commons by the Home Secretary. For the purposes of this paper it is unnecessary to do more than quote the Clause, which defines the classes of persons who are mentally defective and deemed to be defectives within the meaning of the Act. Taken all round, it is a much better Bill than its predecessor of last year, but it should be noted that in the present measure no allusion is made to the undesirability of procreation of children by defectives, or to any intention to penalise persons wittingly bringing about a marriage between defectives. These proposals, which were likely to arouse uncompromising disapproval, may be the less regretted, as their inclusion might doubtless have been instrumental in the blocking of the Bill as a whole. Their effacement, it is hoped, may do away with the opposition which is at present invariably evoked by any attempt to infringe upon the so-called liberty of the subject, and may also give opportunity for educating public opinon, so that in time it may be clear to all that the prevention of amentia can only be attained by life segregation on the one hand, and by the prohibition of marriage on the other. The promoters of the Bill have gone as far as they possibly could in the face of uneducated public opinion, and those of us who were present at the discussion of last year's measure in Standing Committee cannot but admire the courage and resourcefulness of Mr. McKenna in presenting the new Bill after the repeated discouragement which he had to face in connection with his first effort last year.

At the request of the Council, and with your permission, I propose to lay before you this afternoon the following points for your consideration: firstly, the importance of organised after-care in cases discharged recovered or relieved from mental disorder; secondly, the lamentably small proportion of these discharged cases which are brought under the notice of those engaged in after-care; thirdly, the limitations imposed by the constitution of this Association in its practice of after-care; and lastly, certain suggestions—partly the outcome of conversations with your Secretary, Mr. Thornhill Roxby—with a view to increasing the scope of the Association's work.

The object of this short paper is to direct attention to certain clinical cases illustrating the effect of physical illness on the mental state in insanity, and to discuss some points in connection therewith.

Since 1901, when Kruse first isolated his so-called “pseudo-dysenteric” bacilli from an institution outbreak of dysentery in Westphalia, much research on the subject has been carried out in Germany and in the United States, and the bacteriology has been well established. In this country, however, comparatively few outbreaks have been investigated, and of these only a few can be considered satisfactory. As a matter of fact, most of the early work is valueless, as non-selective media alone were used for isolating the supposed organism. Thus in 1898 Dr. Goodliffe investigated an epidemic in the Lancaster County Asylum, and came to the conclusion that it was due to a bacillus resembling B. coli, which he styled “the bacillus of ulcerative colitis.” A similar view was held by Dr. Gemmell in his monograph on the disease. Campbell, working at Rainhill in 1899, cultivated from the fæces of eight dysentery patients an organism which was almost certainly of the coli group, and regarded by him as a very likely cause of the disease. Although conversant with the writings of Chantemesse and Widal, who were the precursors of Shiga and were then actually working on B. dysenteriæ, he apparently failed to realise the significance of their investigations. In 1899 also, an outbreak at Mickleover Asylum was the subject of research by the Medical Superintendent, Dr. Legge, and Dr. Barwise, M.O.H. for Derbyshire. What was termed a “virulent” form of B. enteritidis sporogenes was here regarded as the cause of the disease, having been isolated from eight cases; but a “non-virulent” form was also found in the stools of healthy patients. All these observers, so far as I can gather, employed agar only for primary cultivation, and none of them carried out any satisfactory agglutination tests. In the first volume of Mott's Archives of Neurology, Durham published the results of some work emanating from the Claybury laboratory. He claimed that from the blood, bile and certain abdominal viscera of seven out of eight patients who had died from dysentery he had cultivated a coccus so minute that it was able to pass through the pores of a Berkefeld filter. Cultures were never made from the fæces; subcultivation in a series of generations was found impossible; and the results of agglutination and animal experiments were negative. Dr. Eyre, of Guy's Hospital, was certainly the first in Britain to show asylum researchers the way to a sounder bacteriological knowledge of the disease. Using the Conradi-Drigalski medium, in 1904 he recovered Shiga's bacillus from the fæces of four out of five Claybury patients suffering from the acute form of the disease, and post-mortem from two out of four additional cases, agglutination being obtained with the organisms, and an anti-dysenteric serum in a dilution of 1–200. As the result of further investigation, he found the bacillus of Flexner also present in several of the series, and in a private communication stated that he had detected it altogether in six out of nine acute, and fifteen out of thirty-five chronic cases, none of the latter yielding Shiga's bacillus. Hewlett (1904) tested the sera of two asylum dysentery patients with B. dysenteriæ (obtained from Flexner), and obtained a positive result in 1–50 in one case and 1–100 in the other. In a paper read before the Royal Academy of Medicine in 1905, McWeeny described a bacillus of the mannite-fermenting dysentery group which had been isolated from a severe (subsequently fatal) case in Clonmel Asylum. This organism was noteworthy, inasmuch as it produced no indol, and caused the death of several rabbits while an attempt was being made to immunise them. In the following year Candler, of Claybury, investigated the fæces of six cases suspected to be suffering from acute dysentery. “In five of them an organism resembling the Flexner type was isolated and submitted to the usual tests. The sixth was subsequently proved to have intestinal tuberculosis.” As the result of an examination of five cases occurring in one of the Sussex county asylums in 1908, Bushnell, using Conradi plates, found no dysentery bacilli present, but his report is short and incomplete. An important research was made by Aveline, Boycott and Macdonald of the Lister Institute in 1909. They obtained specimens of dysenteric fæces from Cotford Asylum, and from seventeen out of nineteen Flexner's bacillus was recovered. The spleen and mesenteric gland of a fatal case yielded it also. MacConkey's bile-salt-lactose-neutral-red agar was employed for separation of the organisms by these investigators for the first time in this work. Agglutination was obtained with patients' serum and organisms up to 1–200 and 500, and a multivalent dysentery horse-serum was shown to agglutinate in a dilution of 1–1,000, and when tested to 1–10,000, time allowed being two hours.

The conception of puerperal insanity and of the mental diseases accompanying childbirth and lactation has undergone a considerable change during recent years.

“Let us examine,” says Swift, in his “Digression concerning Madness” in a Tale of a Tub, “the great introducers of new schemes in philosophy, and search till we can find from what faculty of the soul the disposition arises in mortal man of taking it into his head to advance new systems, with such an eager zeal, in things agreed on all hands impossible to be known; from what seeds this disposition springs, and to what quality of human nature these grand innovators have been indebted for their number of disciples; because it is plain that several of the chief among them, both antient and modern, were usually mistaken by their adversaries, and indeed by all except their own followers, to have been persons crazed or out of their wits; having generally proceeded in the common course of their words and actions by a method very different from the vulgar dictates of unrefined reason; agreeing, for the most part, in their several models, with their present undoubted successors in the Academy of modern Bedlam … Of this kind were Epicurus, Diogenes, Apollonius, Lucretius, Paracelsus, Des Cartes, and others; who, if they were now in the world, tied fast, and separate from their followers, would, in this undistinguishing age, incur manifest danger of phlebotomy, and whips, and chains, and dark chambers, and straw.” So wrote the greatest satirist in his pungent and acrid way; and there can be little doubt but that, had he lived to become acquainted with some of Swedenborg's later writings, he would have classified him among that miscellaneous group of “others.” It may seem to some a work of supererogation once more to state the facts which lead to this conclusion; but it is hoped that they will realise that in this recapitulation the object is not to asperse the reputation of a great man, but, by setting forth the story of his life, to show why it was that so great a change was wrought in him, and why he turned from the scientific pursuits of his earlier years to the visionary speculations of his later days. By undertaking such a work a writer is certain to incur the odium of those who rigidly maintain their unshaken belief in the sanity of their prophet; that is regrettable, but regrets will not alter facts.