The subject of my address is one of immense importance to the community, and of particular concern to a very large number of individuals.

This discussion was arranged by permission of the President to afford members the opportunity of considering certain points raised relating to the diagnosis, pathology and treatment of general paralysis in papers read by Dr. J. Brander and Dr. J. F. Smyth at the Annual Meeting on July 13, 1928.

The Main Problem.

The subject to be treated by me on this occasion may perhaps seem to some people almost presumptuous. For psychology is not without severe critics. I can hear one of these saying that, before it takes upon itself to teach others, it would do well to put its own house in order. Is it not, by general admission, passing through a “crisis”? Have not half-a-dozen theories arisen, each of which claims to be the “new” psychology, whereby all the older views are now to be finally superseded?

At the outset it is necessary to point out that although this Report is the result of deliberations extending over a period of four years, it does not profess to deal in an exhaustive manner with every aspect of mental deficiency. The main purpose of the Committee was to consider the problem from the administrative point of view and, whilst many other matters have been dealt with, the subject of mental deficiency is so large that these have necessarily only received somewhat brief mention. At the same time the Report extends over a considerable field, and there is little doubt that it will be regarded as an important contribution to the subject and one deserving of the careful attention of all who are in any way concerned with this class of persons. It is obviously impossible for me to discuss, or even refer to, all the matters which have been dealt with in the four parts of this Report; I shall accordingly confine my remarks to the more salient features.

Studies of the mind of man and of the heart of the frog, though normally deeply divided, can be bridged when two postulates are granted. The first postulate is that the quality of excitability, on which nerve-cell activity is based, can be studied in any other excitable tissue; the second is that mental activity, as we know it, depends on the presence of excitable nerve-cells in the brain. The postulates being granted, it becomes legitimate to apply the results of experiments on excitability performed with the frog's heart in explanation of the mode of working of the brain and mind.

When I first began the study of mental disorders, I realized that patients were, apart from their mental disorder, physically ill, and I was attracted to a study of the circulatory disturbances in these cases. This led me to consider whether these general circulatory disturbances were responsible for the mental state, in the same way that intracranial circulatory disturbances were in surgical brain cases showing mental symptoms. Examination almost invariably revealed weakness of the heart's action, irregularity of the pulse, low or high blood-pressure, and disturbances of the peripheral circulation. It was thus conceivable that disturbance of blood composition and supply might cause disturbance of oxidation in the brain and that many of these abnormal circulatory manifestations might be responsible for the production of mental disturbances. A study of various physiological and biochemical observations suggested that possibly there was in these cases some deficiency of essential salts, such as calcium. This led me to the treatment of mental disorders by the administration of salts of calcium—choosing calcium lactate. Fortunately I found at that time (1919) a very remarkable case showing severe mental symptoms and unusual circulatory disturbances.

In the previous paper on the subconscious and conscious mind it was tacitly assumed throughout that excitation processes, though capable of activating the responding organ, yet are kept within the limits of that organ's capacity to respond. In the case of the heart, however, it was definitely pointed out that the responding organ had a limited capacity to give a normal response; also that the intensity of excitation processes could exceed this capacity (1, 3).

Some few years ago, when the Annual Meeting of this Association was held at York, I had the temerity to inflict upon it a paper dealing with the subject of mental defect. Whether one derives a certain subconscious sense of security in speaking on one's native heath I hardly dare speculate. Whether, on the other hand, the circumstance of propinquity, as it were, to one's roof-tree stirs and stimulates that spark of local patriotism which lies latent in the humblest I leave to the conjecture of those of my hearers who may be psycho-analytically minded and sufficiently interested.

The fact that intellectual effort is accompanied by an increase of muscular tonus was demonstrated by one of us in 1921 (1), the method employed being the registration, by means of a highly magnifying optical lever system, of slight displacement of a relaxed limb. It was found that those muscles which were in a state of postural tension increased in tonus during intellectual work, whilst the fully relaxed antagonists remained unaffected.

Although my object is to initiate a discussion on this subject free from the trammels of the past, I must, I fear, for a brief time deal with it historically.

In considering the significance of double nerve supplies, we shall limit our outlook to the heart, and leave to others the task of applying the results to the wider problems of vagotonia, etc.

In recent years research into mental disorders has tended to become more and more the study of the pathology of the living. The advance of biochemistry has contributed in great measure to this practice. Although bacteriological research has, in recent years, been more extensively undertaken in connection with focal infection, it has, in the opinion of most, yielded disappointing results. The study of focal infection by bacteriological methods alone will not, I am afraid, lead us very far. Endeavour should be made to correlate its local and remote effects in disordered hæmopoiesis, disordered metabolism and disordered endocrines in relation to the internal economy of the patient. In mental disease especially this implies a knowledge of the individual's potentialities that have been predestined by heredity, and later moulded by environment—factors which largely determine the psychopathic tendencies of every one of us. The bacteriological researches of Ford-Robertson and McRae (1) strongly suggest that in mental disorders we are confronted by bacteria of a special type, which as chronic infective agents can probably only adapt themselves to a certain group of the general community having a neurotoxic susceptibility. If, then, we are to make further progress in this direction, we must search for and apply new methods of bacteriological technique, study our results, and attempt to correlate cause and effect. In this relation I shall refer to special methods which are an elaboration of my father's work, the value of which time and experience may prove. In spite of the great importance of the biochemical researches of recent years, I think it will be agreed that some of us, especially those who are clinicians, feel disappointed that so far they have not given us as much indication for scientifically applied treatment as we had hoped. May I suggest that the explanation for this is two-fold. Firstly, in forming the basis of any research the present tendency is to take mental disorders in groups, for example, dementia præcox, which has a wide range of symptoms and between which and other groups it is difficult to draw a line of demarcation. It seems to me that our knowledge of the somatic factors underlying mental disorder is as yet so limited that attempts to continue on these lines will lead us only hesitatingly along the path of progress. Are we not still at the stage where our efforts should be concentrated more on the individual as a problem in pathology which, when solved as far as our knowledge permits, can be correlated in the future with his or her psychogenic group? The second point is that in many instances our scientific work tends to run in too narrow channels; thus it must be frequently lacking in the invaluable support of parallel knowledge in other branches of laboratory and clinical experience. The most obvious example is the lack of adequate collaboration between the biochemist and bacteriologist. I know of no two sciences that can be welded together so opportunely. This combination can be taken a stage further: active and intelligent co-operation with the clinician and X-rays and therapeutic specialists should be sought to enable us to appreciate better the intricate problems we have to face. Some of you may, with reasonable grounds, accuse me of theorizing, and I should at this stage like to mention that before I attempted to put these considerations into practice in cases of mental disorder, I had had the opportunity of carrying out exactly similar lines of research on some hundreds of non-mental patients in hospital and private practice. The majority of them were cases obscure in ætiology and symptomatology. This scientific survey proved to me at least the value of comprehensive work on the individual, and how it enabled one to diagnose and treat many cases with some hope of success. During my two years at Wantage House (the new acute hospital attached to St. Andrew's), I have attempted to carry out what this experience has taught me, with the added advantage that the patients have been under my personal care. Further, there has been every facility for dental and general X-ray diagnosis, and, lastly, ample scope for treatment. The success of such a scheme is only possible by organization and the team spirit, and in this I have been singularly fortunate. The cases I am bringing to your notice are 4 out of some 120 which have been subjected to comprehensive overhaul. I will try to emphasize the salient features in each and correlate them with the mental disorder presented. In this way you can judge for yourselves if we have learnt anything that may in the future lead to a clearer conception of what may underlie at least some forms of mental disorder.

It has often been suggested that functional diseases of the nervous system are caused by intestinal toxæmia, and this suggestion has been revived by certain recent work.

Buscaino (1923–26)has described lesions of the small intestine in mental patients which result in undue permeability of its walls. He also describes a toxic substance in the urine in acute confusional and alcoholic insanity and in dementia præcox. This substance is brought down as a black precipitate by silver nitrate in the cold. The liver is deranged in these cases, and decarboxylates amino-acids presented to it instead of deaminizing them.

In a disease with so widespread a seat as general paresis, in which the cerebral syphilitic changes are local manifestations of a generalized infection, it is only reasonable that an attempt should be made to correlate the cerebral changes with those found in other organs in the same body.

It is well known that the mentally defective population suffers much more from the ravages of tuberculosis in its various forms than does the normal population. In the annual returns of various institutions for defectives, and from a study of the causes of death of imbeciles as reported to the Board of Control, it would appear that tuberculosis kills four times as great a proportion of aments as of normal people. Tredgold (1) gives an analysis of 1000 consecutive deaths occurring in the Earlswood Institution, of which 413 were due to tuberculosis.

Recent decisions in the Law Courts leave the law relating to improper or negligent certification in a very unsatisfactory position; and that not only from the point of view of the medical practitioner. The effect of the decision in Harnett v. Fisher ([1927] Appeal Cases 573) is that a person of sound mind who has been improperly certified as insane through the negligence of the certifying physician, and has as a result of that negligence been deprived of his liberty for a period exceeding six years during which it has been impossible for him to take legal proceedings, is by his failure to do so—in other words, by the very gravity of the wrong that he has suffered—deprived of any remedy for that wrong against the person to whose negligence it is traceable.

During the five years prior to the war I carried out a series of investigations on the treatment of general paralysis. The proportion of general paralytics resident at this hospital was then very high—some 40 out of our usual 350 males. The only treatment given by us up to that time had been mercury and potassium iodide.

Jean Martin Charcot, Physician to the Salpêtrière, and described by his biographer as the Prince of Neurologists, was an Honorary Member of this Association and lived from 1825 to 1893. Though the centenary of his birth, I believe, passed unnoticed in this country, he was in his day a master in clinical medicine and pathology, and his loss was keenly felt both at home and abroad.