It is a fact in Psychiatry which has by no means been sufficiently recognised, that attacks of mental disease have early symptoms that are often not mental in character; and it is equally true that in Neurology the fact has not attracted sufficient attention, that all sorts of sensory, vasomotor and motor symptoms may be the mere preludes to an attack of insanity and not of themselves the real disease. Such prodromata of so serious an event as an attack of insanity are exceedingly well worthy of careful study for many reasons, most notably because the recognition of their true character and their explanation might enable us in many cases to anticipate and possibly to ward off the mental attack. The neurologist who is called in to see a woman suffering from an unusual form of headache, with anorexia, insomnia, and obscure paræsthetic sensations, often misses the real point of the case because he does not realise that such symptoms are, in this particular patient, higher-cortical in origin, and may mean an attack of acute mania in a week if nothing can be done to arrest their course. The psychiatrist often considers a mental attack as being sudden in origin, and puts it down as an unled-up-to mental explosion, when in reality there had been sensory and motor symptoms, sleeplessness, and other indications which would have pointed to the existence of previous auto-intoxication, nerve exhaustion, or other disturbance.

The subject of this paper might almost be said to have achieved immortality, and it may be doubted whether any other woman—in London at any rate—ever attracted the attention of the public to such a degree, or was the cause of so many newspaper paragraphs, during the closing years of the reign of the late Queen Victoria, as the demented inebriate whose morbid character we shall attempt to analyse.

Reviews, abstracts, and papers concerning this subject having appeared from time to time in the Journal of Mental Science, I shall, with the exception of making a few incidental explanatory quotations, confine myself to an account, more or less brief, of some of my own cases and to the remarks suggested by them.

For a considerable period before the now practically universal system of caution cards was adopted in our asylums, other methods had to be resorted to in order that special attention should be given to suicidal patients. In the earlier established asylums, when the various duties, clerical and otherwise, of both medical officers and attendants were less mapped out for them, when, in addition, the number of patients was very much less, the then existing verbal caution was in general use, and was considered fairly efficient.

During the past year we have frequently used antiserums experimentally in cases of acute insanity because we have been led to believe from our observations that many of these cases, either primarily or secondarily, are suffering from bacterial infection. The grounds upon which we base this belief are that we frequently find hyperleucocytosis, and in forty-eight out of seventy-six cases examined we have found bacterial agglutinines in the blood which do not exist in the blood of healthy people.

By the courtesy of Sir Patrick Manson, K.C.M.G., I am permitted to show you specimens of (1) the trypanosoma from the human subject, an European, which is the first instance of such a discovery; (2) in monkey got by injecting human trypanosomes, the specimen being one, I believe, of Dr. Castellani's own preparation; and (3) the Tryp. Lewisi from the sewer rat. I make no apology for drawing attention to the possible cause of a disease—sleeping sickness—which is so nearly allied in its clinical symptoms to the condition of katatonia or hebephrenia, two of the varieties of dementia præcox which, in increasing numbers, many of us are called upon to treat. Recently my colleagues and myself have made an unsuccessful attempt at lumbar puncture in order to have examined the cerebro-spinal fluid of a case of katatonia. Let us briefly contrast the trypanosoma with the malaria parasite.

Considerable attention has recently been directed by several observers to adolescent insanity and dementia præcox, and an increase in the numbers of these varieties, especially of dementia præcox, has been stated to occur, which means an increase in the more hopeless and demented cases. Dr. Wood, for instance, at the Annual Meeting of the Medico-Psychological Association, remarked on the increase in the number of cases of mental breakdown during the age of puberty and adolescence among persons of the upper and middle classes— the ages of which on admission he placed at from eighteen to twenty-eight years—and he suggested as a cause the greater strain of education and the worries of life during the present time. Again, at a meeting of the Section of Psychological Medicine of the British Medical Association, Dr. Robert Jones mentioned an increase of dementia præcox and a general increase of the less curable forms of insanity.

There are probably few conditions which are more difficult to define than hysteria. It is unsatisfactory to make any attempt at generalisation with regard to hysteria, as so many exceptions can be found. It is my opinion that a great many distinct conditions are included under the name hysteria. These conditions are probably as different as epilepsy and migraine. All the various so-called hysterical conditions are closely related to insanity. In many families, whilst one or two of the members are insane, several others are hysterical, and others, again, suffer from allied nervous disorders. I will discuss the varieties of hysteria under the following heads:

There has lately been added to the resources of the Manchester Royal Lunatic Hospital at Cheadle an additional building, a description of which may be interesting to many connected with asylums and hospitals.

In his paper on “Wages, Lunacy, and Crime in South Wales,” Dr. R. S. Stewart asks how such a state of things as he describes is “to be reconciled with the lately expressed opinion that ‘insanity is, and ever will be, the product of two factors, stress and heredity?”’ These words he puts in quotation marks, but I am unable to trace them to any other source. The doctrine that insanity is a function of two variables, heredity and stress, was first enunciated by me some thirteen years ago, and can scarcely therefore be regarded as a novelty now; but, as it is clear, from Dr. Stewart's question and other remarks that he has a very erroneous notion of the doctrine, and as, moreover, it has been misapprehended and therefore misrepresented by others, perhaps you would allow me space to re-state it; although I think that any one who does me the honour to read it in its original form, as set forth in Sanity and Insanity, would scarcely fall into the errors that I have alluded to.