The revised scheme of registration put forth by the Medico-Psychological Association three years ago and officially adopted by the Commissioners in Lunacy is a noteworthy attempt to impart greater accuracy and precision to the record of facts relating to the insane. An important feature of this revision was a full and carefully designed schedule, compiled by a special committee, intended to replace the long-established list of the “causes of insanity,” which, whilst doubtless reflecting the knowledge of the middle of last century, lacked scientific precision and had become obsolete. The new schedule aimed at greater definiteness, and being framed on the teachings of experience by those most competent to the task, may well be considered to fairly embrace the whole field of ætiological inquiry. It is with the object of showing what may be learnt from its use that I have ventured to lay before the Association the results of a study of the records of the institutions for the insane in England and Wales during 1907—the first year of the adoption of the revised system—in so far as these refer to patients suffering from their first attack of insanity.

There are certain persons who, having taken alcohol to excess, develop a form of insanity characterised by distinctive features, clinical and pathological. [This is the form which I mean by “alcoholic insanity.”]

Surveying insanity as a whole, one recognises as a fundamental fact that insane persons belong to a class who start life with a “deficient grade of organisation” of the nervous system called “hereditary predisposition.” Some authorities hold that this is the sine quâ non of insanity, but such a view, I consider, is not strictly accurate. It is certainly not borne out by statistics. All observers, using even indifferent discrimination, must have noticed cases in which no hereditary factor could be traced, but in which much self-abuse had occurred—either in the form of alcoholic, sexual, and other excesses—or where syphilis or other powerful toxæmic conditions had been contracted. Such conditions, I argue, may themselves break down the most hardy constitution and leave it a prey to secondary infections or intoxications, which may manifest themselves as insanity. Assuming that the insane, prior to their attack of mental disease, suffer from either some hereditary weakness, or some acquired constitutional degeneration, it is most probable that such defects act a dual part, weakening not only the nervous system, so that it is more susceptible to the actions of toxins and environments, but also weakening the natural defences of the body. The nervous system of these people is thus laid open to more severe and frequent attacks from poisonous substances, whether of bacterial, metabolic, or other sources, than is the nervous system of a more normally organised individual. In support of this statement I would mention that Dr. L. C. Bruce has pointed out that over 60 per cent. of maniacal patients were deficient in the normal protective agglutinin to certain strains of Staphylococcus aureus. This agglutinin is always present in healthy sera. Further, Dr. C. J. Shaw has ably demonstrated that the reason tubercular diseases account for so large a proportion of the deaths in asylums lies, not in any faulty hygienic precautions, but in the fact that the resistive power of the insane to tubercular infection is below par. Assuming that this hypothesis is true, we can more readily understand why the various insanities so frequently resist our efforts to cure them.

In May, 1907, we published the results of our first series of experiments dealing with the question of toxic absorption along the lymphatic paths of nerves and the effects upon the spinal cord, medulla, and pons.

A Granular condition of the ventricular ependyma, especially that of the fourth ventricle, has long been recognised as one of the most important of the post-mortem lesions of general paralysis. In the opinion of the writer it is present in at least 90 per cent. of the cases, and the more carefully the examination of the ependyma is made, the greater will be the percentage of cases showing granulation in asylum post-mortem books. In the Journal of Mental Science, July, 1905, the writer recorded the frequency of this condition in an analysis of 131 consecutive post-mortems on male paralytics at Wakefield Asylum, and on 112 male and 19 female cases at Horton Asylum. The percentages were 878, 90, and 100 respectively. Blatchford (Journal of Mental Science, 1903, p. 483) states 70 per cent. of paralytics were recorded as exhibiting granular ependyma, and of the non-paralytic deaths 16·6 per cent. of men and 5·3 per cent. of women. There were 83 paralytic deaths and 369 non-paralytic. The writer is convinced that granularity of the ependyma, especially that of the fourth ventricle, is the most valuable naked-eye diagnostic sign of general paralysis. This statement is supported by that of Bolton, who considers the most characteristic naked-eye sign of dementia paralytica to be granularity of the ventricular ependyma, referring specially to the lower half of the fourth ventricle.

The interesting paper by Dr. Turner published in this Journal upon the blood-pressure in the insane has led me to make these few remarks, which I have based upon a large number of observations obtained by Martin's modified Riva-Rocci sphygmomanometer. I attempted besides taking the systolic pressure to estimate the diastolic also, but my results in the latter case were not satisfactory, for so many likely errors were always present.

In the mass of conflicting evidence which has accumulated in recent years as to whether organisms are the exciting factor in the production of certain insanities, I have found it difficult to discriminate between cause and effect. Is the organism or group of organisms the specific pathogenesis of certain insanities or merely a bacteræmia secondary to the psychosis?