Gentlemen,—I feel that some apology is due in bringing before you a series of rather trivial cases of mental disorder, in which there is nothing very new, and whose interest really lies in their being placed together for special consideration. Experience teaches me that one may often learn more from the slighter deviation from health than from the more serious perversions. In the former one may watch the details much more readily than one can in the latter.

That it would be impossible for anyone in a single paper to adequately treat of the mental symptoms occurring in bodily diseases is self-evident. For it must be remembered, as Maudsley says, “that it is impossible to be out of sorts physically without being out of sorts mentally,” so that the subject includes not only the slight emotional changes found in various diseases, but also the actual insanities produced by or accompanying them. All that I propose to do in this communication is to give a short account of the mental changes which I have noticed during a four years' residence in the Manchester Royal Infirmary, and during a longer experience as visiting physician to the Manchester Workhouse Infirmary, where I have charge of over 800 medical beds.

I have nothing to say on changes of mental state due to loss of thyroid activity; the psychosis of cretinism [is well defined and widely known. But I venture to think that the mental changes of exophthalmic goitre are equally defined and not perhaps as widely realized. If this be so, if there are such distinct types of mental aberration, in marked antithesis to each other, which accompany two pathological states of the thyroid, perhaps also in antithesis, this is sufficient to give the subject a place in our discussion.

The mental changes which accompany disturbances of the viscera may be classified under two groups, as follows:— (a) Those changes which accompany the disease directly, and are associated with the presence of some abnormal product or tissue change produced directly by the disease (for example, myxædema). These may be called the direct mental effects of visceral disease, and will be neglected in this communication. (b) Certain mental changes which are only present in those cases where the visceral disturbance causes what is known as referred pain associated with tenderness of the superficial structure of the body and scalp. Now this pain and tenderness are due to changes in some part of the central sympathetic system caused by disturbance of the internal organ to which sensory sympathetic nerves are supplied. Thus the mental changes of this group may be said to be indirect, for they are associated with visceral disturbances through the mediation of the sympathetic system. In this communication only the sensory and emotional changes are considered.

At the outset it should be stated that, if the term diabetes is to necessarily include the three cardinal symptoms—permanent glycosuria, polyuria, and thirst—the term glycosuria should be added to the title of this paper. For several of the cases upon which it is based, and which, at the request of Dr. Claye Shaw, I am about to communicate to the Association, exhibit little beyond more or less permanent glycosuria. But, inasmuch as there is no abrupt line of demarcation between classical cases of diabetes and those where one or more of the symptoms are absent, and inasmuch as it has already been pointed out by other writers that the presence of mental symptoms is apt to mask the bodily ones, and, further, since allusion will be made to a few possible cases of diabetes insipidus, it has been deemed best to adhere to the original title which appeared in the list of subjects suggested for discussion at this meeting.

The fact that considerable attention has been drawn of late years, both in the medical and lay press, to the subject of operations undertaken for the relief of idiocy and other mental deficiencies of child-life, must be my excuse for taking up the time of this section with observations resting, not alone upon my own limited experience, but largely on that of others. The operation of craniectomy, or as some prefer to call it linear craniotomy (that is the cutting out of strips of bone from the skull), has, indeed, almost passed from the domain of science to the region of romance, and articles have appeared in several of our popular magazines under such sensational titles as “Creating a Mind,” which have led parents of mentally-deficient children to form extravagant conceptions of the powers of surgery in this direction. It may not, therefore, be inappropriate for medical men to weigh and measure the evidence which has accumulated during the last five years as to the possibilities and impossibilities of operative interference in these cases.

When Lannelongue published his accounts of his first cases of craniectomy for microcephalus, the hope was raised that microcephalic idiocy would prove a curable form of mental deficiency, and would come to be classed among the ordinary surgical diseases of children, as being mainly a bony deformity to be remedied by the use of the knife and the saw; and though Lannelongue himself did not follow Virchow's teaching and regard premature ossification of the cranial sutures as the primary cause of microcephalus, but attributed it to its actual cause, namely, arrested development of the brain, still he considered that there was undue compression and consequent dwarfing due to bony pressure, and that craniectomy would relieve this and lead to increase of brain growth.

The object of this paper is to state briefly what appears to the writer to be the law as to voluntary boarders in asylums (under which term is included all English institutions for the reception of persons of unsound mind), to narrate the practice observed in such cases at Bethlem Hospital, and to gain information from those members of the Association who are engaged in the treatment of mental disease as to their practice.

Law is often, I fear, somewhat unsatisfactory. In no class of cases is it more so than in those in which it attempts to carry out the clauses of the last Lunacy Act relating to single patients.

It has always appeared to me that the various figures that are supposed to indicate an increase of insanity are not only inconclusive, but do not really show anything of the sort, and that there are even some vague and indefinite indications that there is really a decrease in the annual production of insanity. Some years ago I tried to find some figures amongst the various statistics we possess that would throw some light on this point, but practically without success. It seemed that such increase in the annual admissions to asylums as was beyond that due to increase of population was more than accounted for by slighter (i.e., less demonstrative) cases of acute insanity and various forms of chronic, senile, and degenerative disorders being yearly sent to asylums more freely, but I could get no figures proving this. A somewhat suggestive fact in this direction is the often-made remark that acute mania is less abundant, melancholia more so than formerly; acute mania of an active (i.e., demonstrative) type was always sent to asylums pretty well up to its actual amount. Melancholia used to be very largely left at home or treated in workhouses. But where shall we find such facts embodied in figures. Acute mania of our statistics includes the milder as well as the more demonstrative cases, and so shows an increase just as the total figures do. There are, then, so far as I know, no figures showing the real annual occurrence of insanity that are comparable year by year. There are, indeed, no figures that give the actual annual production of insanity apart from chronic and recurrent cases. There are no figures of any definite form and intensity of acute insanity. True the Commissioners' Reports give us statistics of general paralysis, but this is precisely the one form of acute insanity that is not an insanity; that is, it belongs to a different natural order of diseases from the other diseases we mean by insanity. I have elsewhere stated that this always appears clearly on a comparison of the statistics of general paralysis with those of insanity proper, and the same opinion has been expressed by authorities who have approached the matter from a pathological and therapeutical standpoint. Its remarkable geographical distribution and its specially urban character equally show it to be different from the other insanities, which have no similar features. That this disease is increasing owing to the more and more urban character of our population affords no ground for assuming a similar progress in the true insanities. The annual recoveries must, however, be largely dependent on, and proportional to, the annually occurring cases, but will, of course, so regarded, be vitiated by the increase of population and by the increased admissions of milder forms of insanity and by the recoveries of recurrent cases.

Within the last two years no less than three Parliamentary Reports, dealing with the problems presented by the familiar phenomena of inebriety and recidivism, have been published, and a measure designed, and, to a large extent, calculated to carry the main recommendations embodied in these documents into effect, has been read a second time in the House of Lords, under the pilotage of the then head of English legal administration. These facts show that public opinion has at length been thoroughly aroused as to the necessity for fresh legislation on the subject of habitual drunkenness and crime, and render any preliminary historical sketch of the growth of the movement, which is apparently at last on the eve of attaining its objects, superfluous. If there is any member of the medical or legal profession who is still in ignorance of the process by which the problems in question have been brought to the stage of perfect ripeness for legislative solution, he may be referred with confidence to an admirable summary of the Parliamentary history of legislation affecting inebriates by Mr. Legge, the Secretary to the Inebriates Committee, 1891, which forms the 6th appendix to the minutes of evidence taken by that body, and is reproduced, with some additions and alterations, as Appendix M in the evidence taken by the Scottish Committee of 1894, and to the three Parliamentary Reports which have suggested the present review (see note, sup.).

I do not wish to enter into any dissertation on the question of mechanical restraint, as such, or to conduct the discussion in to an academic debate on the ethics of mechanical restraint. I want to take a more limited view. I want this discussion really to be, if possible, an interchange of views as to the best way of treating and managing certain difficult and exceptional cases which crop up every now and then. I propose to give you the benefit of my experience in dealing with some exceptionally difficult cases, in which I have found a modified use of mechanical restraint beneficial to the patient.