The following pages contain an account of the microscopical examination of the central nervous systems of forty-one cases of idiopathic epilepsy, which form the data on which I base my thesis that epilepsy is a disease occurring in persons with a defect of the nervous system either congenital or involutional, and in whom also there is an abnormal state of the blood, characterised by a special tendency to intravascular clotting, and that the fits, whether of the nature of grand mal or petitmal,owe their exciting cause to sudden stasis of the blood stream in some (generally limited) portion of the cortex, resulting from the blocking of cerebral cortical vessels by these aforementioned intravascular clots. I have already in a paper read at the pathological meeting of the Neurological Society in December, 1905, and published in the British Medical Journal March 3rd, 1906, given a short account of my views, but it was impossible in the limit of time at my disposal when reading the paper to deal in any but a very cursory way with many interesting aspects of the question, nor could I then give sufficient details of the microscopical examination of the individual cases.

In the daily routine of medical work we are called upon to deliver what may come to pass. The constant weighing and measuring of our observations and experience lead us naturally to an estimation of probabilities. Recovery or death—success or failure in the appointed strife with disease—that is the momen tous question to which the physician must endeavour to find an answer. Things have happened; what is to come to pass? Much of skill in prognosis is personal, empirical, and incommunicable; but, as our science advances, with the contributory aid of all the sciences that are subordinate to the master art of healing, so, in just proportion, our premonitions will be determined.

The honourable position, which, through your kindness, I am privileged to occupy to-day, associates the occupant of this chair with a long roll of distinguished predecessors, and unites him as it were to a confraternity of honour which oversteps time and unites generations. But whether the initial duty of having to deliver an inaugural address is a wise one, I will not venture to say; yet I do know that the consciousness of this time-honoured custom neither tends to produce peaceful repose, nor happy thoughts during the year of probation. My immediate predecessor, Dr. Robert Jones, having so diligently covered the field of evolution, from the time of King Saul to the latest conceptions of the London County Council, I have experienced no little difficulty in finding a resting-place in any of the ordinary fields of inquiry. Assuming that the members of this Association would not expect anything new in what I might say, I have speculated whether, perhaps in directions which are not new, I might say anything which would suggest useful thought to those interested in the aims and work of our Association. On the very threshold of my task I was, as if by chance, suddenly pulled up, and found written across my path these words: “I look into my glass.” Such is the title of the short address with which I purpose troubling you this afternoon. Would that this glass were the simple artificial mirror from off the reverse side of which you and I could re move the silver coating and look into the fathomless abyss beyond; but no, the glass is the human mental mirror of which all are possessed, some more, others less. If I propose to you to look with me into this glass at the question of the social aspect of insanity in a purely rural district, “far from the madding crowd,” and which has remained untouched from the influence of large communities, it is not as a mere theoretical exercise in race evolution, but because it contains within, a further inquiry, which even in this the early part of the twentieth century may be turned to profitable account in an Association like this.

In the “children's Crusade” we witness the enormous credulity of the Dark Ages in its simplest form, although the delusions which the children indulged in must have been encouraged by their parents. The orders of the King of France to stop their pilgrimage had evidently been disregarded. Was it that a whole people had become mad? Some writers have argued that nobody is quite sane; in that case we should need another word for those who cannot do without restraint.

This class contains sixty-five cases of presenile dementia–i.e., of insanity ending in dementia, and occurring between the periods of maturity and of senility. Of the 728 cases of insanity under consideration, the present class, therefore, includes 9 per cent., and of the 445 cases of dementia 14.6 per cent. Though attention has already been drawn to the distinction which is necessarily made between “presenility,” an age-period in all individuals, and “prematurely induced senility,” it is perhaps permissible to remark here that cases of the latter type have been included in the class of “senile or ‘ worn-out ‘ dementia,” which was described and illustrated in the last section of this paper.

We have already pointed to the great practical importance of the measurement of fatigue in traumatic neuroses. It is particularly important for our purpose because, as we have already observed, exaggerated fatigue is always present in this disease, and so it gives the best opportunity of testing the general applicability of our method to the clinical measurement of fatigue.

When a few months since I was asked by Dr. Bedford Pierce to address the nursing staff of this time-honoured institution it was a moot point in my mind whether I should take as my thesis some general subject connected with the history and profession of nursing or direct my remarks to you in a more personal appeal than so general a theme would permit.

Recidivism is the French coined term most appropriate to express the persistent, reiterated lapses of the same individual, in that small section of habituais found in every country, both among criminals engaged in serious crimes against the person and property, and among petty offenders, whose delinquencies or misdemeanours are drunkenness, public disorder, prostitution, and vagrancy. The former are aggressive, noxious, anti-social, and, to a slight extent, industrious and productive; the latter, as a rule, are passive, idle, debauched, parasitic, and unproductive. The two types are quite distinct, and there is little or no inter mingling; that is to say, the recidivist engaging in the major crimes in the criminal calendar does not forsake the ranks of that class to become a recruit in the ranks of the minor and petty offender class, and vice-versâ.

During the past year I have systematically employed rest in bed in the open air as a special method in the treatment of all patients newly admitted to the Ayr District Asylum; and during the past six months I have carried out the same method in the treatment of all resident patients exhibiting relapses or phases of active insanity, the latter including the most difficult and most dangerous cases in the institution. At present, there-fore, all patients in Ayr Asylum who manifest their insanity in such active forms as marked morbid excitement, exaltation or depression, distinct delirium, confusion or stupor, vivid hallucination and delusion, active homicidal or suicidal tendency, impulsiveness and the like, are being treated by the method of rest in bed in the open air, a method which may be conveniently termed the sanatorium or open-air rest treatment of active insanity. Although it is yet too soon to speak as to the ultimate therapeutic value of this system, and several years must necessarily elapse before its effect on the recovery rate in insanity can be definitely ascertained, even a short experience has sufficed to demonstrate the immediate benefits and strong points of the system, and to show that it is a more satisfactory method of treating those who are actively insane than either the outdoor exercise or indoor rest procedures hitherto in vogue, and that, indeed, it secures the advantages without the disadvantages of the exercise and rest systems combined. The particular combination of rest in the recumbent position and in the fresh air of the open would indeed seem to be Nature's specific for at least the alleviation if not the cure of an attack of insanity; and the method is not only based on sound physiology and correct pathology, but it is so easily carried out in practice, it so obviously benefits the health of the patients–not to mention also that of their nurses–and withal it is so pleasant a remedy both in the receiving and the giving, that even a comparatively short experience of its employment has convinced me that the systematic open-air rest treatment of active insanity has come to stay, and that at no distant date it will secure a wide sphere of application in asylum practice, and in the treatment of the psychoses and neuroses outside of asylums. Before describing the sanatorium treatment of active insanity I wish to put before you the stages in its development, and to show how, after an apprenticeship in the exercise system of treating active insanity, I came to adopt the rest method, and by allying the latter with the open-air cure, as suggested by the modern treatment of pulmonary tubercle, I arrived at the combined method of rest in bed in the open air, which has been in vogue at Ayr Asylum during the past year.

Brazil, with its vast area, comprising a fifth of the western continent, its various climates, and its population of 2 1,000,000, formed of several ethnical groups, offers an admirable field for the study of the comparative racial pathology of the insanities.

Death-Rate statistics of persons dying in large institutions are often inexact, as their accuracy depends to a very large extent on the personal factor of their compiler. Unfortunately, the statistics of the death-rate from tubercular disease, particularly phthisis, occurring in asylums leave no room for doubt that the insane, as a class, are particularly liable to contract tubercular disease. The English Lunacy Commissioners in their report for 1902 say: “The proclivity of the insane, whether confined in asylums or not, to tubercular disease, especially pulmonary, has long been recognised.” In all asylums, according to Clouston, who was amongst the first to draw attention to the fact, consumption is between three and four times more common than in the general population at the same ages.

The investigations that have led us to employ specific vaccines and antisera in the treatment of general paralysis and tabes dorsalis have been the subject of several previous papers, the last of which formed the basis of a discussion at a meeting of this Association on May 16th. It is necessary, however, to state here in a few words the more immediate reasons which seemed to us some eighteen months ago to justify the undertaking of these experimental observations of therapeutic aim. Prior to their initiation we had definitely ascertained that a threading diphtheroid bacillus, isolated from the brain and the bronchus of a rapidly progressing case of general paralysis, was capable of producing a subacute disease in rats, in which the symptoms were distinctly comparable to those of general paralysis, that on postmortem examination of the animals the brain showed the characteristic changes of general paralysis, and that there was also the characteristic invasion by the thread form of the bacillus. It was thus evident that among the various species of diphtheroid organisms that can be isolated from a general paralytic there is at least one capable of producing the disease general paralysis. We had also ascertained numerous facts which harmonised with this view. We had obtained cultures of a diphtheroid bacillus from the brain of the general paralytic in ten out of twenty-four cases; and whilst attempts to cultivate the organism from the blood and cerebrospinal fluid of the living patient had, as in the experience of most other observers, been in most instances entirely negative, we had succeeded in obtaining pure growths from the blood in four cases and from the cerebro-spinal fluid in two. We had also ascertained that diphtheroid bacilli, in a more or less advanced state of disintegration, are frequently recognisable in these fluids, even when a culture cannot be obtained, and that such altered bacilli are almost constantly present in the walls of the inflamed vessels of the brain in cases dying in a congestive attack. We had also evidence of the occurrence of a diphtheroid cystitis in all of several cases of tabes dorsalis examined, and of the existence of a high intracorpuscular bacteriolytic index to certain diphtheroid bacilli on the part of such patients and of general paralytics, which we interpret as denoting that they were defending themselves against the attack of an organism of this kind.

In his paper on “Amentia and Dementia “Dr. Bolton has intercalated such a vigorous dissent from some of my speculations on the localisation of cerebral function, and a complaint so bitter of my criticism of some of his earlier researches, that I am forced to offer a defensive response.

THE following is an account of a systematic examination of the coagulation rate of the blood of nine female epileptics and seven healthy women.

In a previous paper we described the lesions in the posterior columns of the spinal cord in cases of general paralysis, and pointed out their similarity with those in early tabes dorsalis. We showed that the degeneration always commenced at the point where the posterior roots enter the cord. It is here that the sensory fibres become part of the central nervous system and lose their neurilemma sheath; and in all cases we found that precisely at this point degeneration began.

The normal English child has thriven apace of recent years, as the result of a healthy popular tendency to foster his mental and physical well-being as thoroughly as may be. But there exists among the poor a race of unfortunates–happily a small one–whose interests have rarely met with adequate recognition. It consists of the imbeciles who find their way into pauper lunatic asylums–the children legally certifiable as idiots. They cannot, I admit, pay a dividend in hard cash on the money sunk in their education, and their appeal for special attention mainly rests on their helplessness. My aim is to speak briefly of the measures already taken in their interest elsewhere, and to describe in a little more detail those adopted with success at Hellingly. Lastly, I propose to discuss the cost of our scheme, and to attempt to analyse the benefits derived therefrom.