There is a constant endeavour in psychiatry, as in other branches of medical science, to distinguish between organic and functional disorder. Year by year, in most of these other branches, the organic group becomes larger, the functional group smaller. But unfortunately the same cannot be said for psychiatry. When all is said and done, the term “functional disease” is largely a cloak for ignorance. Where there is disease there must be something to show for it, but if the changes are so subtle as to escape detection, we at once label the condition “functional.” General paralysis was considered a functional disease until it was proved to have a very solid anatomo-pathological basis; indeed, until this proof was forthcoming it could hardly be said to exist as a definite entity at all. Until this process is extended to other forms of insanity, clear thinking in psychiatry is impossible. We are still far too prone to look only upon the mental side of the cases which come under our care, whereas we ought diligently to search for some physical causal factor that may be at work, and for corresponding physical changes that may give us a clue to such a factor.

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.

Ladies and Gentlemen,—By your choice I find myself in an honourable position to which in no flight of imagination had I ever aspired. A cautious habit of limiting aspiration by what seems to be the attainable has no doubt saved me from many a disappointment; now it affords me a surprise in a form which to all men is ever the most gratifying—an expression of good-will from those whose opinion is valued most highly, one's comrades and colleagues.

The proposals for legislation as contained in the Mental Deficiency Bill are here dealt with under the following heads, viz.

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.

Our conception of the ætiological significance of myxœdema in reference to those forms of mental disorder generally known under the name of “insanity of myxœdema,” has undergone considerable modification since the time when hypothyroidism was regarded as the principal causal factor. The almost dramatic effect of thyroid treatment gave rise at first to a justifiable optimism. This for a while tended to obscure the possibility that a deeper-lying disorder of mind might exist, which would be naturally brought into prominence by the peculiar disturbance in the functioning of the brain associated with this state of disordered metabolism.

Before attempting a classification, it is desirable to define what we exactly mean by insanity. It is not an easy matter. Who is to say where the dividing line is to be drawn between the sane and the insane? The one state passes insensibly into the other, and a division, which may be valid in certain circumstances, may not be so in others.

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.

One of the most striking developments of recent years, a development which may be seen in most countries of the civilised world, is that of the recognition of the necessity for preventive measures against disease. This necessity is not only felt in medical and scientific circles, but is, in many instances, quite as keenly appreciated by members of the general public. Few people are now indifferent to an outbreak of a serious infectious disease even in a distant land; and, in case of an outbreak in our own land, we no longer patiently watch it run its course far and wide without making strenuous efforts to check it, but by investigation we try to ascertain its cause, and by segregation and fumigation we keep it somewhat under control. The report of the spread of the “plague” in Eastern Asia at once led to an inquiry as to our preparedness to prevent its being introduced into this country, and to combat it if it gained an entrance. We have now an army of inspectors whose duty it is to watch our food-stuffs, and the way they are handled, to investigate the conditions under which our working classes are asked to labour, to inquire into the surroundings in which the people live, and to prevent pollution of the air and water. We have a service in many parts of the country to instruct mothers how to feed and attend to their children, and the children, when they go to school, are examined to discover whether they are suffering from any disability which would hinder their making use of their opportunities, or which, if not corrected, would tend to become aggravated.

The above was the subject or text of the Presidential Address delivered by Dr. Mabille, the Medical Director of the Asylum at La Rochelle, in France, on the occasion of a Congress of the French-speaking alienists at Tunis in April, 1912.

Double personality is a fascinating subject, and has always possessed a peculiar attraction both for the professional psychologist and the layman—owing, no doubt, to the strange and often dramatic character of its manifestations.

Certain features of the speech defects commonly seen in general paralysis bear a resemblance to aphasia, e.g., inability to find required words, and the tendency to omit syllables or words without noticing it, or to transpose syllables or the vowels of successive words. More definite aphasia, however, may occur in general paralysis either as a transitory or lasting symptom. Though it may arise under a variety of conditions it is distinctly uncommon.

It is now generally granted that a post-graduate training for medical men desirous of taking up lunacy as a speciality is essential in order that the study of the causation of insanity may progress along scientific lines, and accurate co-ordinated observations result therefrom, but it is equally necessary that the conditions and circumstances of these men on taking up work in asylums should conduce to the best interests of the speciality in question and tend to bring out the best qualities of the medical personnel. A moment's consideration proves that such conditions are conspicuous by their absence.

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 position of the assistant physicians in the German asylum service and the conditions under which they worked were investigated by a Committee of the German Society for Psychiatry in 1908. In January of that year a meeting was held in Berlin at which Dr. Hans Wachsmuth introduced the subject under the title “Conditions of the Medical Service in Asylums—Independence of consulting physicians (Oberärzte) and hospital physicians (Abtheilungsärzte) and the duties of the assistant physician (Assistenzärzte).” This paper was published in the Psychiatrisch-Neurologische Wochenschrift in February, 1908, and in a letter which I received recently from Dr. Wachsmuth he stated that considerable improvement in the service had been made during the past four years.

The excuse for a discussion on this physical affection in association with the insane mind is an attempt to prove by its rarity in county and county-borough asylums, asylums for idiots, mental hospitals and licensed houses of England and Wales, that it is preventable. In ten years from 1902 to 1911 there are recorded by the English Commissioners in Lunacy seventy-five deaths from appendicitis, typhlitis or perityphlitis, ascertained in the majority of cases by post-mortem examination, as having occurred among the insane population of the above institutions. and of the seventy-five deaths it would be instructive to know how many of these had the relics of this disease upon them or were suffering at the time of admission from acute or chronic symptoms. In making the statement that appendicitis is a rare malady in private and public hospitals for the insane, I do so with the support of several practitioners of psychiatry. Not only do these clinical observers give me their assistance, but further I have the help of the pathologist to the London County Asylum at Claybury who states, “I do not believe there has been a single case of appendicitis on the post-mortem table at Claybury since I have been pathologist. Consequently in more than 2000 post-mortems there has been no case.” In comparing the Claybury Hospital for the insane with two general hospitals, St. Bartholomew's and Guy's, we can make a valuable contrast. For instance, at St. Bartholomew's Hospital 1645 autopsies were made between 1909 and 1911, and of these, 69 were recognised as appendicitis. At Guy's Hospital in the year 1900, of the first 500 post-mortems 12 were recorded as cases of appendicular disease. As regards the proportion of cases of appendicitis to the number of admissions I find that at the same hospital in 1890 there were 8588 admissions. Of these admissions, 306 were subjects of appendicitis, 187 being under the care of surgeons, while 119 were under the care of physicians. The death-rate from appendicitis recorded in the Registrar-General's Report for 1909 shows a slight gradual increase from 1901 to 1909. Referring to other parts of the Kingdom in this investigation I find the statistical tables from the Lunacy Board of Scotland show that formerly deaths from appendicitis were usually returned as deaths from peritonitis, that appendicitis had no separate heading in the Board's tables of causes of death, and is not yet separately notified. If a case of appendicitis were returned it would be placed in the table of Diseases of Digestive System; but it has been ascertained that no death in a Scottish asylum has been returned during the past five years as due to appendicitis. Again the Blue Book of the Inspectors of Lunatics for Ireland in the issue for 1911 gives typhlitis grouped among the causes of death, but the table gives no return of the complaint for that year. and in the table there are only eleven cases of peritonitis. Likewise the Secretary of the Office of Lunatic Asylums, Dublin Castle, sends me the returns for typhlitis for the period 1902 to 1910 as follows: 1902, o; 1903, 1 male; 1904, o; 1905, 1 female; 1906, o; 1907, 1 male; 1908, 2, male and female; 1909, o; 1910, o—viz. five in all. and the cause was ascertained, except in one case, by post-mortem examination. With these figures for your guidance I would remark that in experimental research and statistical calculations, extreme care and accuracy should survive comment. But with the greatest attention and thoroughness that any of us can spend on the subject matter of a professional inquiry in medicine, exception will be sure to prove the rule.

The subject of the few remarks I have to offer is one with which those who attend the insane soon become familiar. No other class of physicians can speak of it with more authority. It is not a wide field, and at the first blush would not appear to lend itself to much divergence of view. Yet from the opinions one occasionally hears expressed, I think it is expedient that our attitude towards the questions associated with artificial feeding should now and again be reviewed. When to feed artificially, its relative dangers, its moral effect, or even the best method to adopt, are points upon which observers differ.

The study of eugenics is attracting an increasing amount of attention and interest from scientific men, legislators, and society in general.

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.