It is sometimes cast up as a reproach to those engaged in psychiatry that zeal in research, and progress in knowledge in this subject have not kept pace with other departments of medicine, but I now describe some valuable additions to our knowledge which have all been made during the last decade on the diagnostic signs of general paralysis of the insane. Although the full title of this disease is a perpetual reminder of the fact that the credit of its discovery belongs to physicians engaged in asylum practice, it is desirable to drop the final qualification, and refer to it simply as general paralysis.

The treatment of bacterial diseases by means of specific vaccines is a branch of therapeutics that has been steadily growing in importance in recent years. It is now being applied to every bacterial infective malady, from acne to acute septicæmia. Nevertheless, it is admittedly only at an early stage in its development. Every worker at the subject is still endeavouring by observation and experiment to improve its methods, to understand better its mode of operation, and to determine the extent of its useful application. It has already had brilliant triumphs, although, in common with other forms of medical treatment, it has to admit many failures. While it is now being extensively employed both in general and in hospital practice, it has not yet been utilised in our asylums as it deserves to be. The chief purpose of this paper is to endeavour to show some of the useful applications vaccine therapy may have in such institutions, and to encourage its employment.

When, towards the end of August, your Secretary wrote and asked me to give you a paper to-day on villa asylums, I was just arranging to start on my holidays, and I hesitated at first to accept his invitation, as I saw little or no prospect of being able to give the time necessary for the preparation of a paper worthy of the occasion. But, on the other hand, feeling more or less the responsibilities of a parent, seeing that this institution was in a great measure the outcome of my advocacy of the villa system, I felt compelled to make a special effort and try and give you something which would at any rate form a basis for what I hope may form a useful and interesting discussion.

Dr. Sidney Coupland, in opening the discussion, said: I need hardly say that I have read Dr. Gettings' paper with great interest, and have found it, as other readers must have done, very instructive as well as entertaining. What gives particular interest to his graphic story is the fact that it is based upon the continuous medical records of an institution for nearly a century, and in this respect it must surely be unique. From a remark in the paper, apparently more zeal in clinical note-taking was exhibited in the earlier than in the later period of the history of Wakefield Asylum, but I feel sure that, if this be so, the lapse can only be temporary. As regards dysentery, it is certainly remarkable that a disease, once fairly common in this country, should have almost entirely disappeared from the community at large, a disappearance which seems to have coincided with that of the last serious visitations of cholera in the middle of last century. Even if we accept the usual explanation that these diseases, like typhus, have been banished in consequence of wide-spread improvement in urban and rural sanitation, especially as regards drainage and water supply, we yet cannot ignore the fact that many an insanitary area still exists which à priori might be expected to favour the spread of such disorders. We know, too, how great a scourge dysentery has been to armies in the field, where conditions of fatigue, exposure, imperfect diet, as well as defective sanitation, favour the development of intestinal disorders. My own limited experience confirms the fact of the rarity of dysentery in the general population. During the past thirty or forty years the average number of cases of dysentery admitted into the wards of the Middlesex Hospital has not exceeded one per annum, and in the seven years (1873–9) that I worked in the post-mortem room I only had to examine two subjects of dysentery, one of whom had contracted the disease in India. I was therefore much surprised to find, on joining the Lunacy Commission, that almost daily notifications were received from asylums of deaths from “colitis,” mostly ulcerative in character, and clinically indistinguishable from dysentery, as had been well shown by Dr. Gemmel just about that time. Dr. Gemmel's monograph, published in 1898, was founded on his personal observations at Lancaster Asylum, where for some years “idiopathic ulcerative colitis” had prevailed. It would, therefore, seem as if dysentery, whilst dying out from the population at large, had found a habitat in asylums, whose inmates, owing to their careful segregation, were less liable to most of the zymotic diseases. Regarded as an infective disease, which Dr. Gettings holds to be a sufficient explanation of its persistence in asylums, one can well understand the difficulty in getting rid of it once it has gained a footing, owing to the conditions of asylum life, and the faulty habits of many of the inmates. But it is only of late that it has been so regarded, for it has been customary to ascribe its occurrence to bad sanitation, of which, indeed, colitis was almost considered to be an index. Such a view seemed to be supported by instances like those mentioned by Dr. Gettings in the Wakefield Asylum, of outbreaks of dysentery coinciding with grave sanitary defects, the removal of which was followed by the subsidence of the disease. A classical instance is that of the outbreak at the Cumberland and Westmorland Asylum in 1864, reported on by Dr. (now Sir) Thomas Clouston, then its medical superintendent. The outbreak, which was a severe one, and accompanied with a high mortality, was connected with the irrigation of fields adjoining the asylum with untreated sewage. Col. Kenneth Macleod referred to this epidemic in a discussion at the Epidemiological Society in 1901, and said that when he himself was assistant medical officer at the Durham Asylum in 1864 there was a similar outbreak of dysentery also, and, as at Garlands, it was associated with sewage irrigation. These and similar instances all lent support to the opinion that dysentery resembled enteric fever in being a “filth disease,” meriting as much as the latter the appellation of “pythogenic,” which Murchison applied to typhoid.

The problem of leucocytosis has been the subject of much discussion in recent years. Amongst the earlier workers on the subject Virchow stands prominent, and he first gave the name of leucocytosis to a temporary increase in the number of leucocytes in the blood, this occurring both in physiological and pathological conditions. During the past twenty years special attention has been paid to this phenomenon, bringing to light some very important information. Amongst later workers Metchnikoff has done more to enlighten us as to the problem than any other worker. To briefly recapitulate his doctrine. The leucocytes protect the organism against harmful germs by catching them up in their pseudopods, by investing them, and thus robbing them of the possibility of exerting their deleterious action externally. The termination of an infective process would therefore depend alone on whether leucocytes possessing this function are present in the blood in sufficient numbers to overcome the invasion of the germs. The doctrine of Metchnikoff has been modified and also extended by other workers, notably Denys, Löwy, and Richter, who have proved that the value of the leucocytes does not depend on their pseudopods, but that their chemical products yield the strongest protection to the organism. The leucocytes are able by means of the bactericidal or antitoxic substances which they give off to paralyse the toxins produced by the bacteria, and in this way render the microbes harmless by depriving them of the weapons of attack, even if they cannot destroy them.

The following short paper is based upon observations made during the examination of the cerebro-spinal fluid from a series of cases of various forms of mental disorder. A good deal of attention has recently been paid to the examination of this fluid in conditions of disease; there have been numerous observers, and several important tests have been devised. In this series of cases a routine examination was followed in every case, which embraced the tests described by Noguchi, and by Ross and Jones, an examination of the cells present, and an estimation of the amount of albumen in the fluid. It is to the last of these methods of examination only that attention is directed in this paper.

Though the subject of enteric fever would not seem to come within the purview of this Association, yet special features, mental and otherwise, of the outbreak in Omagh Asylum in the end of last year prompted me to put some of the facts before the members of the Irish Division. They will pardon me if they find my remarks rather bald, being mere records of observations, but I hope they will not be altogether uninteresting.

In the year 1850, Baillarger published an account of a new symptom which he had frequently observed in general paralysis, namely, inequality of the pupils.