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.

At a time like the present, when the claims of psychogenic treatment are attracting the attention not only of the medical, but also of the lay mind, it befits those of us who believe that beneath every mental process there lies a mechanical basis to take careful thought whether we are altogether blameless if comparatively easily understood psychological explanations of disease are substituted for the far more intricate and complex physiological, and to ask ourselves whether we have in fact always applied to the problems of nervous physics the knowledge we actually possess. We turn to text-books of mental diseases seeking enlightenment, and are put off by vague explanations, no more convincing and far less logical than those advanced by the psychologist, nor do we find any reference to much work on the physical nature of mind which has long been known, although, indeed, twenty years ago Crookshank made an effort to correlate physical signs with mental. conditions, and five years ago Dunlop Robertson drew attention to the importance of adrenalin in the production of depression. We do not know much about nerve action, but we do know something, and if we are not willing to apply to our own special work the simpler tests of the physiologist and the chemist we are in danger of seeing our teaching discredited; and therefore I have decided to address you to-day upon one class of mental illness which comprises two distinct processes, and to endeavour, by tracing the conditions present in both, to offer some explanations, not indeed of the ultimate, but of the proximate causes which may underlie each in turn. The two processes are involution and depression, and my title is: “The Mechanism of Involutionary Melancholia.” None of my facts are new, none have been worked out by any special labours of mine, but as there may be some who, like myself, banished in the depths of the country and many hours distant from a medical library, find a difficulty in marshalling current knowledge into its ordered place, I give these deductions for what they are worth; for the psychology of melancholia is the depressive emotion, and the anatomy of the depressive emotion is a sympatheticotonus, and the chemistry of a sympatheticotonus is an endogenous anoamia.

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.

In their fourth Annual Report, published in 1918, the Board of Control drew attention—not for the first time, but in more extended form than hitherto—to deficiencies in the arrangements, as at present organised, for the treatment of persons suffering from mental disorder, especially in its incipient and early stages; to the insufficiency of attention paid at medical schools to this important branch of medical science with its consequent ill-effects both to patients and to the medical profession; and to the absence of any special qualification in psychiatry, as a requirement for the higher medical posts in public institutions for the insane, such as is demanded in public health of medical officers of health of areas of above a stated size.

Half a century ago Maudsley wrote “A pregnant but very difficult question of which little or no thought has ever been taken by writers on insanity is—What is the cause of the particular form which the disorder takes in a given case? Why does it assume one complexion rather than another? At the outset it is certain that what appears to be the same cause shall occasion different forms of insanity in different persons and even in the same person at different periods of life, and that the same form of disorder shall be produced by different causes; this being so it is plain that the special determining conditions lie hidden in that unknown region which we call by such names as ‘temperament’ and ‘idiosyncrasy.’”

Dr. Matsumoto, who came to study neuro-pathology under my direction, having acquired a thorough knowledge of the methods employed in investigating the histology of the central nervous system and the endocrine glands, expressed a desire to study the microscopic specimens which I had prepared during the last six years of the testes and resicula: seminales in one hundred cases of all ages dying in hospitals and asylums from injury or disease. A full report of this work was published in the British Medical Journal of November 22nd, 29th, and December 6th, 1919.

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.

For several years past my attention has been directed to a series of cases in which the principal symptom has been the presence of hallucinations.

(With the permission of the Prison Commissioners.)

It is well known that with the grosser lesions of many of the ductless glands there are profound alterations in the subject's mental powers. There are doubtless many less pronounced mental alterations due to slighter lesions of these glands which are for the most part unrecognised—in fact difference in character and disposition in different individuals and in the same individual at different times may be due to the variation in the balance of the internal secretions.

When Noguchi found spirochaetes in the brain of general paralytics some years ago it seemed as if we were entering into a new era, not only in the pathological conception of the so-called “parasyphilitic” or “metasyphilitic” affections, but also in their treatment. In this latter respect most of us have hitherto been somewhat disappointed, and it may therefore be advisable to take up the rationale of the treatment for revision.

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:

Until the outbreak of hostilities in August, 1914, the number of cases of mental disorder associated with head injury investigated by any one individual must of necessity have been very small. Hence the sparcity of literature on this subject. Never before the outbreak of the late war have so many men been engaged in armed conflict against one another, and never before have arms of such a destructive kind been employed.

Upon the outbreak of the recent war, most of us, after experiencing a transitory phase of almost breathless suspense, passed, I think, into a state of apprehensive ignorance.

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: