Gentlemen,—I feel I owe the honour of having been selected to deliver this first Maudsley Lecture, not to any special fitness I possess to expone any of the more recent developments of that branch of medicine, the furtherance of which the lectureship is intended to promote, but to the fact that I am almost the last survivor of those who were associated with the founder of the lectureship in the early days of his professional career. While still a student at the University, Maudsley was revealed to me in a brilliant essay on Edgar Allan Poe, which was published in the Journal of Mental Science in April, 1860, and which, although too scathing and denunciatory of the ill-fated poet, as it now appears, was so rich in insight, originality and happy similitudes as to betoken unmistakably “the lighting of another taper at Heaven,” which was at that time Maudsley's way of describing the arrival of a new man of genius on the scene. A few years later I made Maudsley's personal acquaintance at the table of that gracefully-refined and highly-gifted physician and philanthropist, Dr. John Conolly, who afterwards became his father-in-law, and in the years following I can recall many memorable meetings with him at “The Lawn,” at Hanwell, in his rooms in Queen Anne Street, and in a restaurant in Soho, where, over frugal meals, he and I and Lockhart Robertson, and Broadbent and Harrington Tuke and Baron Mundy of Moravia, the zealous advocate of non-sequestration and family life and free air for the insane, held high discourse and adumbrated projects for the future of lunacy, some of which have taken shape since then, while others remain unrealised and perhaps unrealisable.

Some of you may remember that, four years ago, I inflicted upon you a paper dealing with almost the same question. It was entitled “Some Examples of Neurotoxic Bacterial Action.” Since that time I have continued, in the Laboratory of the Scottish asylums, the practical study of bacterial infections on a fairly wide basis, and I believe it is now possible to define with something approaching exactness the part which such infections play in the causation of mental disorders, including insanity. It can now be shown that this part is a very much larger one than at present is generally believed. The same can, however, be said with equal truth regarding the relation of infections to common maladies.

The social problems connected with alcohol are always before us, but social reconstruction after the great war has brought them into greater prominence than ever, while America having gone “dry” and the prohibition campaign starting in this country have brought the question of alcohol home to even the unthinking section of the community. In the past we have had the physiological effects of alcohol put before us almost ad nauseam, and everyone is fully aware of the disastrous wide-spread results of excessive drinking. Well-meaning temperance reformers are continually pointing out the intimate relationship existing between alcoholic excess and illness, crime and pauperism. Not so very long ago in the press, we had the almost amusing incident of a manifesto issued by a list of eminent physicians, who decried its use in medicine, followed not long afterwards by another manifesto signed by an equally eminent catalogue of medical men, who laid much emphasis on the beneficial effects of alcohol as a therapeutic agent. The personal factor is always apt to colour one's views, and I may be no exception to the rule. It is a common fallacy to suppose that science is free from bias and prejudice, but the facts I shall bring before your notice with regard to the relation of alcohol to mental disease will tend to indicate their presence.

The clinical evidence of acidosis is the detection of acetone bodies in the urine. Acetone is formed from diacetic acid by the splitting off of carbonic acid, the origin of diacetic acid being in part from fats and in part from proteins. Oxybutyric acid is also formed from diacetic acid by reduction, consequently the presence of acetone bodies in the urine always means that acidosis is taking place. A delicate test is that known as Rothera's, which is quite simple, and will detect acetone in minute dilution:

The cases dealt with in the present paper came under review during the course of my duties as Medical Officer to the Leeds Committee under the Mental Deficiency Act. They comprise examples of the four varieties of mental defectives defined by that Act, viz., idiots, imbeciles, feeble-minded, and moral imbeciles, and include most of the clinical types described by writers on the subject. The commonly accepted division into primary and secondary groups has been adopted; a third group, containing cases which appear to combine the characteristics of both types, and a fourth group containing “doubtful” cases, in which the data are insufficient to allocate them definitely, being also added. It has seemed useful, too, to give columns showing the number of cases corresponding to the accepted clinical types, those complicated by epilepsy, those exhibiting pronounced stigmata of degeneration, as well as those showing a definite family history of neuropathic affections, tubercle, or alcohol respectively. It is obvious that many of these cases will figure under the several heads. The following analysis then shows the proportion of cases under each of these heads of the total number of cases examined, viz., 200:

A widower, set. 69, was admitted recently to the Glasgow Royal Mental Hospital in an anxious, apprehensive, excited, restless state. The history of the case showed that he had come of a good stock, and that he had been a strong, healthy man. For a period of forty-six years he had been employed by the same firm of lawyers, and latterly had been their cashier. He had married twice; there were four children from the first marriage and two from the second. He had divorced his second wife on account of her unfaithfulness. In January, 1919, he resigned his position, sold his home, and made plans to live with his daughter. Three days after his home and furniture had been sold he made a determined attempt on his life by cutting his throat. One month later he was admitted to the Glasgow Royal Mental Hospital. Following his admission he continued in a state of abject misery, he moaned and groaned, wrung his hands, resented any interference, and was very restless. He realised that he was in a hospital, but his mind was so occupied by his depressive thoughts and he was so miserable that he would not assist in a satisfactory mental examination. Physically he was in poor general health, his pulse was irregular and intermittent, and he had peripheral arterio-sclerosis. During the next few months he gradually improved in strength and general condition but mentally panics of anxious apprehension supervened from time to time, in which he became self-accusatory, and expressed hopeless feeling as regard his prospect of recovery. At the same time he was perfectly oriented, and his memory, general knowledge, and personality were all well retained. No particular attempt was ever made at psycho-analysis (his age seemed to preclude such a procedure), but nevertheless casual conversations* were sufficient to allow him to give expression to his fears, and incidentally to show where his conflicts and difficulties lay. He complained of the other patients, said that they looked as if they could tear his bones out, that they wished to do him an injury, that they slandered him, that they accused him of incest with his daughter. At this point he began to defend himself with great warmth and emphasis, and said, quite unnecessarily, that the only thing that supported him was the consciousness of his own rectitude, that nothing had been further from his thoughts, etc. These matters were never argued out with him, but he was encouraged always to say what he had to say, and eventually six months after admission he was discharged as recovered.

So many of our readers subscribe to the British Medical Journal and the Lancet that we do not as a rule epitomise original articles which appear in these publications, unless they are of outstanding importance or there is some other special reason for so doing. The same attitude is adopted, but to a less extent, as regards other English medical journals, most of which are easily obtained. Economy, always a necessity, is especially important at present. There are some subjects, however, including contemporaneous movements of moment affecting the psychiatrical world, it is important that members of the Association should be kept well informed of, hence the “Epitome” and many of the items published in “Notes and News.”

In this article of 71 pages Prof. Janet deals with the question of the influence which neuropathic subjects exert upon those with whom they are associated. Each point in this paper is emphasised by reference to actual cases, and it contains a wealth of clinical detail which cannot be included in an epitome. To understand fully the therapeutic value of isolation, and to apply it with precision, it is necessary to consider the costly effort which life in society exacts, to consider the influence of one man on another, especially in so far as one individual by his exactions may create a state of lowered psychological tension in another with whom he is associated. A study of the social conduct of a neuropath in relation to his family will indicate how and why separation from certain persons is so important in some instances. These psychasthenics exhibit social abulia, avoidance of any effort, lack of practical achievement; they can neither command nor obey, they are incapable of real affection, and though they talk much of their feelings, these result in no kind of service for others. Not only do they protect themselves from actions which they dread, but they hinder and oppose others in the family and have the whole household at their mercy. There are a number of morbid impulsions and inferior mental operations by means of which the neuropath dominates the family. Thus there is the mania for helping, in which the individual wishes to participate, and actually hinders, the activities of others, an exaggeration of that tendency of those incapable of physical exercise to watch sports or read sporting papers. A patient expresses this attitude in the phrase, “My dream is to sit with a man who works, especially a man who writes. Oh! let me watch you write for a whole evening.” This tendency may extend to an insistence on useless and futile collaborations. Then there is the mania for authority. Giving orders when it implies direction and initiative is a difficult psychic operation, but there is an elementary form of domination in which an individual formulates an action without accomplishing it himself and without any consideration as to the value, utility or interest of the act. Neuropaths find in such orders extreme satisfaction and at times people placed in positions of authority develop a mania of this kind. Neuropathic authoritatives are divided into two types, those who seek to obtain obedience by moaning entreaties, and those who attack and threaten the members of the family in order to reduce them to slavery and to prevent them from having any freedom. Such patients will obtain their desires by threatening to die if they are thwarted, or by insisting on constant sympathy, any relaxation of such an attitude provoking a scene. Obedience is also secured by the mania for love, the constant demand for every expression of affection. Prof. Janet points out that all these abulics are extremely insistent on their “rights,” whereas the man of action is not worried with his rights but devotes himself to the task in hand. Domination is sometimes secured by the mania for devotion, in which individuals are constantly rendering little services and giving useless presents to others, such generosity having always something bizarre and abnormal, designed to humiliate and exact innumerable thanks. It is only a method of acquiring recognition, protection, regard, flatteries, of playing a rôle.

Life is dependent on the energy around it. Being marked by the quality of growth, it must not only seize the energy through its protoplasmic structure, there transform it, and then put it forth, but it must unceasingly devise new means, new carriers for all these three processes. Human speech is such a means. Not consciously but unconsciously, man has made words because he has felt, though not understood, the necessity for a larger and wider self-expression—for more capture of energy, more work upon it within himself, and more giving of it out.

As effects of excitement may be noted—(a) those which are transitory, occurring during the excitement, and (b) those which persist. As transitory effects there may be an apparently general hypermnesia, in which there is a marked freshening of all memories, or there may be a selective hypermnesia, where certain rather narrow lines of association are followed. The lasting effects may be hypermnesia, hypomnesia, or total amnesia for events experienced during the excitement. The following lasting effects may also be noted upon experiences that have occurred before the emotion: (1) The well-known retro-active amnesia; (2) The opposite, retro-active hypermnesia to which little attention has formerly been paid; (3) a combination of both these effects; for the same person the stretch preceding the critical event may show vivid recollections followed by a period of utter blank. The retro-active hypermnesia in the author's cases rarely goes beyond the events of the day preceding the excitement. It occurred in 25 out of 225 cases. The antecedent events are unusually vivid—more vivid than any other of the patients' memories. The vividness is not confined to visual images, although these are more frequent; sounds, the mood, the general state of the mind may be clearly represented. There is some indication that women experience it more frequently than men. In some cases the effect has come at some crisis at early childhood, in others at a later date. The quality of the emotion seems of less importance than the intensity of the shock. Fear, or fearless surprise, or pleasurable surprise may be the cause. If the intensity be exceeded the experiences connected with it are in some degree suppressed; while if it be not reached the experiences are lost probably by a mere failure to gather up the events into the mesh of interest. Emotion facilitates the recall of whatever is noticed during the excitement, and it seems probable that memory images may be treated by the emotional onrush in the same way as perceptive images. The experiences of the preceding day, however, probably do not exist as actual images at the time of the emotion but as psycho-physical dispositions or traces, so that where there is retro-active hypermnesia the emotion would seem to have the power to strengthen these dispositions and the connections by which they may be called into life. The author gives illustrative cases.

The author gives the results of his control measurements of sections from various cortical areas. He used a special block-holder, equipped with a scale, and rotatable, so that from one block of cortex seven or eight planes of section could be made, cutting the cortex at as many different angles. All the measurements were made at the apex of convolutions, where the axes of the majority of nerve-cells pass vertically into the white matter. The depth increments referable to obliquity are tabulated as percentages of the shortest measurement. He concludes that, using sections cut and mounted with extreme care to avoid undue obliquity, one may expect an error of something under 6 per cent., of which almost one half is due to difficulty in determining the line of demarcation between cortex and white matter. The fixing of this line is somewhat arbitrary, owing to the rather gradual and straggling manner in which the spindle-cells of the lowest cortical layer disappear as the white matter is reached.

A married woman, æt. 40, began to have difficulty in doing her work, complaining of headaches, which gradually became more severe. Her memory gradually failed for both recent and remote events. After about seven years walking became difficult, and finally she was bedridden, being unable to stand. A tremor of the hands developed, and it was necessary to feed, dress, and care for her. No syphilitic evidences; Wassermann negative in blood and spinal fluid. No sclerosis of peripheral arteries. Blood-pressure 160–80. Pupils irregular, the right dilated; reaction to light slow, to accommodation nil. Tactile appreciation slightly impaired; inability to localise readily for touch or space; wincing to pin-pricks. Knee-jerks exaggerated. Right ankle clonus. No Babinski. Marked tremor of hands, tongue and lips. Speech retarded and slurring. The clinical condition much resembled general paralysis, except for its protracted course and the negative Wassermann. Diagnosis, “cerebral tumour?” Died comatose at the age of 48.

This prolific writer here surveys the diverse opinions of authors respecting the significance of injury in the ætiology of general paralysis, since the first description of the disease by Bayle in 1822, and gives eighty-four references. He considers that injury can act neither as a determining nor as a predisposing cause, and that it is very doubtful whether it can act even as an occasioning cause. Injury can, of course, accelerate or aggravate a pre-existing general paralysis, but it is not certain that it can give rise to the disease, even in a syphilitic subject. On this point, scientifically, an attitude of the greatest reserve is necessary, but for medico-legal purposes it is often right that an injured person should have the benefit of the doubt. The writer sets forth the differential diagnosis between traumatic dementia (strictly so-called) and post-traumatic general paralysis. His account of the medico-legal aspects of the question is mainly of French interest.

The writers consider that many diagnostic mistakes were made in war psychoses owing to the tendency to crowd cases into one of the two great pigeon-holes, manic-depressive insanity or dementia præcox, and that in many instances little attempt was made to understand the cases as reactions in terms of personality, conflicts and wishes. Many cases showing symptoms of these psychoses occurred in unadaptable individuals and the disorder readily cleared up upon removal to hospital. Many illustrative cases are given which enable the writers to conclude that: (1) affective disorders were frequently mistaken for dementia præcox; (2) psychoses showing typical schizophrenic development had recognisable benign features; (3) acute confusional hallucinatory psychoses with fear were incorrectly diagnosed as dementia præcox; (4) acute paranoia was a relatively common psychosis; (5) the distinction between psychosis and psychoneurosis is untenable.