At the annual meeting of alienists, in Switzerland, in 1888, Wille directed attention to the writings of Felix Plater, who practised at Bâle nearly three centuries before, and in these writings are to be found the first definite descriptions of general paralysis; but it was not till after Willis in 1672, Haslam about 1800, and Bayle twenty years later, had each independently described the disease, that any great interest was awakened in it. Since that time, however, it has furnished a fruitful source of interest and discussion to many physicians, which has not only been abiding, but as the disease began to be better understood, has increased to a wonderful extent.

The cause of the Imbecile has for some time past been a plea which has never failed to elicit the practical sympathy of the public; yet much remains to be done before we have fulfilled our obligation to those who are not lunatics, and are capable, under suitable conditions, of being made self-supporting members of the community. As in this paper I intend to deal chiefly with the future of the improvable imbecile, I think that in the first place the statement that such an individual after training is independently capable of earning his own livelihood is as absurd as it is impossible. I shall presently endeavour to show that without supervision little or nothing can be expected from an imbecile, however highly trained and educated he may be; his whole disposition and temperament away from control completely negatives the supposition, and actual cases have proved that, unless under sympathetic and intelligent guidance, the life of the imbecile as far as usefulness is concerned is not only a blank, but that the individual himself is a burden, and in some instances a nuisance to society and his friends. Secondly, there can be no doubt that much of the careful and patient instruction bestowed upon such cases at the educational establishments is wasted, for the simple reason that at the expiration of their term there many improved imbeciles gravitate to conditions totally unsuitable for them, and under which it is almost impossible to expect that the training which they have received will, so to speak, have a fair chance. On completion of their term of training it may be that in some cases the parents are dead, and there are no relations or guardians to look after them; for a large number there is nothing but the workhouse. Again, their imbecile temperament causes others, perhaps in a moment of pique, to abandon the work which has been obtained for them possibly only by a vast amount of trouble, and they thus become a burden to their relatives. A third section are, away from supervision, incurably vicious, and many in the course of their career become gaol-birds and convicts. The imbecile is one who is totally, or in part, bereft of the faculties necessary to enable him to take a successful part in the battle of life, and I think that it may be safely assumed that, in the whirl of this nineteenth century, with its attributes of high pressure and overcrowding in every direction, the imbecile can of himself secure no place. His appearance, his mental and often physical deficiencies, are all dead against him, and his unstable equilibrium, manifested in uncertainty of temper and morals, renders him in many cases quite unfit to be trusted away from proper care and supervision. In fact, it is unjust and unfair to forget this by exposing these individuals to risks by trusting them too far.

After many years of agitation and controversy, the first instalment of a much-needed reform of the law as to inebriates has been conceded by the Legislature. The aim of the present article is to subject the Inebriates Act, 1898, which came into operation on January 1st, 1899, to a somewhat minute and critical examination, in the hope at once of suggesting points for future amendment, and of throwing light on difficulties that may arise in its practical administration.

G. D—, æt. 69, admitted September 21st, 1896, for the eighth time. He was maniacal on admission, and had remained so for twelve months.

In January, 1898, he commenced to complain of pain on micturition; his urine was strongly alkaline and contained pus. He stated that two months previously he had inserted a piece of vulcanite pipe stem into his urethra. On passing a sound no foreign body was detected in the urethra, but a stone was felt in the bladder.

We are, for obvious reasons, forced to gauge the prevalence of phthisis in asylums by its mortality. Several questions at once present themselves:

What is the mortality from phthisis at the present time in the British Islands ? What is the mortality from phthisis in the asylums of the British Islands ?

Are these mortalities diminishing or increasing ? And what relation do they bear to one another ?

It is easy to propound these questions; it is extremely diffi cult to properly appraise the available data. For, first, if it be desired to compare the mortality from phthisis of asylum inmates with that of the general population, the comparison must be made on the basis of the ratio, in each case, of the annual deaths from phthisis to the average populations in volved. In other words, the phthisis death-rate, and not the percentage of deaths assigned to phthisis, must be estimated.

During a period of nearly twenty years' management of a private asylum for middle-class patients, and a like period of consultation practice in our specialty, I have had constantly brought to my notice the difficulty—very often, indeed, the impossibility—of finding proper accommodation for insane patients unable to pay fees of more than fifteen to twenty-five shillings per week, and the difficulty has vastly increased with the increasing numbers of pauper lunatics who now crowd out the already very small number of private patients provided for in county and borough asylums.

A complete microscopical examination of the following case was made with the hope that new light might be thrown not only on the pathology of the disease itself but also on some of the disputed points of cerebral anatomy.

It would perhaps be allowable to take it for granted that the number of suicides has been steadily increasing in most of those countries which furnish us with trustworthy statistics, but after the discussion in Section E at the last meeting of the British Medical Association, I think it better to go over some of the reasons which have led me to subscribe to the view generally received by those who have carefully inquired into the subject.

Since the middle of the nineteenth century psychology has gradually come to be recognised as a branch of biological science. This is due to the influence of the works of Darwin and Herbert Spencer, of the Clinical and Neurological School of Meynert, Golgi, Cajal, Flechsig, and others, and recent developments in the Psychometric School of Fechner and Wundt on the other. The Alienistic School can render powerful aid to this movement; and though there are indications of the current in the proper direction, as shown more particularly in the work of Mercier (1) and Bevan Lewis (2), the end, however, cannot as yet be said to have been achieved, nor the movement to have become general. Psychology still lingers on the borderland of metaphysics; it has not yet been established on the firm rock of natural science. And while it thus lingers progress in knowledge is slow and restricted.

Dr. Mott.—Before I was intimately associated with lunacy I was astonished to find in my hospital experience that nervous diseases were so frequently due to syphilis. I therefore adopted the treatment of giving mercury and iodide in all doubtful cases. In regard to general paralysis, I agree at first with those authorities which believe that syphilis had little to do with it; but careful examination of the patients and postmortem investigations convinced me that syphilis plays an important rôle in this disease.

The necessity of a cognizance of those Acts of Parliament affecting asylums in their capacity as large employers of labour has become more obvious of late by the operation of an Act which came into force in July last—“The Workmen's Compensation Act”—where, for the first time in British law, a responsibility has been cast upon an employer to pay damages or compensation for personal injuries which are not the result of any negligence or other unlawful act, either of himself or his servants for whose conduct he is legally responsible.

Although the condition of acromegaly existed and was described many years ago, its recognition as a morbid entity practically dates from the year 1886, when Dr. Pierre Marie, of Paris, named and defined it as a disease characterised by great overgrowth of the hands, feet, face, and head. Since then the disease, though rare, has been universally recognised, and more than 200 cases have been reported. Of these some have been typical, some atypical, and some have not been acromegaly at all.

The subject of the present paper has occupied my attention for more than two and a half years, and during the whole of that time I have felt deeply indebted to my colleagues both at Bethlem Royal Hospital and at the Lancashire County Asylum at Prestwich for the generous way in which they have afforded me every opportunity of studying the subject. Some of these gentlemen have not only permitted me to examine their cases, but—knowing my interest in the subject—have, at inconvenience to themselves, drawn my attention to cases which would otherwise have escaped notice, and have further assisted and encouraged me by confirming my own observations. I therefore take this opportunity of most heartily thanking all these gentlemen for their valuable help and kindness.

Whilst it is the object of this paper to deal with the subject in the main as limited by the title, it is well that some consideration be given to the general literature bearing upon the relations between diseased conditions of the uterus and appendages and diseased conditions of the mind.

In the Neurologisches Centralblatt for July 15th, 1898, Drs. Luithleu and Sorgo describe a method of staining the central nervous system, which at that time I believed to be new. However, Dr. Wright, in the summer number of Brain for the same year, and therefore about the same time, referred to, without describing the same method, so that it is obvious that it had already claimed some attention from neurologists.

As an introduction to this paper I have detailed three cases as clinical pictures. My conclusions are based on an examination of sixteen cases, six of which proved recoverable. Case No. I is an example of recovery and illustrates the condition found; but it presented no congestive attacks, which sometimes occur during the course of such a case. Cases Nos. 2 and 3 show in addition confirmed muscular and degenerative lesions precluding any chance of recovery; in both, however, there were distinct remissions.

It is now about four years since Drs. Bruce and Macphail first published the results of their treatment of cases of insanity by thyroid, and since then the new drug has been used very extensively in the Royal Edinburgh Asylum. Dr. Bruce has published the results of his further experience there, and though they are not quite so encouraging as those first carried out at Derby they have furnished several remarkable cures, and have shown conclusively that in thyroid we have a decided addition to our means of treatment.

We think it will be generally acknowledged that the problem which the treatment of noisy, destructive, and dirty patients sets to their medical officers is greatest as regards their management at night. It is then undoubtedly that noise, destructiveness, and dirty habits have the greatest chance of getting free play, and it is then that the efforts for reformation have to be greatest. If these efforts are successful considerably more than half the problem will have been solved. It is to this part of the question, viz. the supervision of such patients during the night, that we desire in this paper to direct attention. At the outset it may be stated that our proposals are not theoretical. They are the result of practical experience gained during the past four years in the Sunderland Asylum. The special arrangements we propose to describe were instituted by one of us at the opening of the institution four years ago. At first a few cases were dealt with tentatively, but, as the first results were so encouraging, the number of cases was gradually increased, until all the patients who were restless, noisy, destructive, or of dirty habits came without exception to be dealt with. The asylum, situated at Ryhope, is a small one, containing only 350 beds, and on this account, as well as because it was new, it was conveniently suited for such an experiment. It may be well before going further to describe the arrangements now in existence there. There are 175 beds for each sex, made up as follows:—45 single rooms, one fully padded, and 2 half-padded; 2 small dormitories of 7 each, 2 of 13 each, 2 of 19 each, and 2 of 26 each. In the last two there is a night attendant, and one also in one of the dormitories for 19, which is the hospital ward. There is, in addition, a head night attendant who visits the patients in these dormitories and also all the remaining patients every hour, or oftener when necessary. There are thus 4 of a night staff for 175 patients. Though this is probably a large proportion compared to most public asylums, it is not claimed as a new departure in asylum management, as we are aware that in a number of asylums the advantage of having a large night staff is fully realised and acted on. The essential feature of the arrangements at Ryhope, to which we wish to direct attention, is the selection of cases placed in dormitories under constant supervision. Of course, all epileptics and suicidal patients are placed there. But, in addition, all recent cases of whatever kind, all dirty and destructive cases, and those who sleep badly and are in consequence inclined to chatter or be noisy, are also placed under constant supervision. Looked at from the other side, all single rooms and dormitories not under constant supervision are reserved for quiet and well-behaved patients who do not require any special attention during the night. This plan has been found to work exceedingly well, and since it was organised we have never had occasion to think of adopting any other. Another testimony to its effectiveness is that those of the staff who have the actual supervision of the patients and have had experience in other asylums are unanimous in their opinion that the arrangement is a very decided improvement. This opinion, let it be observed, is not based on the ground that now their duties are lighter than they were, because, as a matter of fact, they are more onerous.

In introducing the subject upon which I have the honour to address you, I am actuated rather by a desire to raise a discussion than to state any new theory or fact. It is some time since the “Care and Treatment of the Epileptic” was discussed at a meeting of this Association. Since then, and more particularly recently, there has been a further broadening of our ideas as to the sphere of work of alienists, and attention directed to the conditions of life of classes of people with whom we are not in touch in our routine daily labours. This has followed upon, and in some degree been associated with, the widening of our ideas as to the mental states we include under the term “insane,” and certifiable as such, a consideration which is in part answerable for the so-called increase of lunacy.