II. Criminal lunatics.—A brief note as to this class of patients will be of interest. Professor Meyer has very decided opinions as to their care and treatment. He fears that the practical outcome of advanced theories would be to change asylums into prisons—a change that would by no means possess the charm of novelty. According to some authorities the term “criminal lunatic” should be limited to such persons as were criminal before they became insane; others would include all insane persons who have committed an offence against the penal laws; some have even stretched the phrase to include all those whose mental condition would lead one to expect impulsive misdeeds, moral insanity, etc. The Academy of Medicine of Belgium gave an authoritative opinion on this subject in 1889. In answer to the inquiries of the Minister of Justice regarding criminal lunatics and criminal asylums, they resolved that these classes should be regarded as criminal, and should be relegated to a special institution— 1. Any insane person who has committed a criminal act. 2. Any criminal who has become insane after sentence. 3. Any insane person confined in an asylum who has committed or attempted a criminal act. In the special asylum, accommodation would be provided for all those insane persons presenting on examination homicidal irresistible and violent impulses, or similar evil habits.

The term “insanity” conveys to the minds of lawyers and physicians two different meanings, based on two divergent methods of testing its presence, and a clear recognition of this fact would go far to prevent many misunderstandings which arise solely from the logical error of equivocation. The term insanity as used by each should of course be accurately defined, and the difference of meaning thereby made plain; but this has not been done, for to prepare an accurate and satisfactory definition of insanity appears to surpass the wit of man. Even had it been done in a theoretically perfect manner it would probably be of little or no value, for, like Mr. Herbert Spencer's definition of life, it would of necessity be so abstract as to give no assistance in practice. For my purpose here it will be sufficient if I indicate the lines on which the legal and medical definitions of this term would run.

We propose in this paper to deal with the subject of the effects produced upon mental disorders by intercurrent bodily disease. The theme is an old one, but we feel justified in calling attention to it afresh, partly because it is at present prominently before the minds of many alienists, partly since those who have concerned themselves with it—in this country, at any rate—have principally been content with the mere indication of the facts observed. The pathology of the subject, the domain of experimental research and scientific speculation, remains comparatively unexplored. Our literary survey leads us to conclude that but little has been written upon this subject of late years.

My apology for bringing forward this subject at the present time is that considerable interest with regard to it has recently been evidenced by correspondence and comments in the medical journals, as well as by inquiries set on foot by the Lunacy Commissioners and the Local Government Board. The former have published in their 49th Annual Report, just issued, a “Return showing the Number of Pauper Idiot, Imbecile, and Epileptic Children in the Asylums, etc., on 1st September, 1894,”† and a return of similar character as to such children in workhouses has been issued by the latter. The upshot of the whole matter is that, according to these returns, there are in lunatic asylums 525 children of this class (335 males, 190 females), and in workhouses 485 (281 males, 204 females). The latter number includes, however, 93 children returned as “epileptic only,” so that of idiots and imbeciles in workhouses under 16 years of age there are but 392. Adding together those in lunatic asylums and in workhouses we find that a total of 917 youthful idiots and imbeciles are provided for by the Poor Law in these institutions. The Local Government Board return, however, gives us no information as to the large number of such children living with poor parents who receive on their behalf some parochial relief. In the Commissioners' return the children are classified as idiots and imbeciles respectively, 399 in the former, 126 in the latter class; and 154 are said to be in the opinion of the medical officers likely to be improved by special training. In the Local Government Board return the children are classified as “imbecile only,” “epileptic only,” and “both imbecile and epileptic;” and the number of children who, in the opinion of their medical officers, would be likely to be improved by special training is set down as 178. Consequently if we are guided solely by these returns we should be led to the conclusion that in England and Wales—excluding the Metropolitan district, for which separate arrangements exist—there are no more than 332 improvable pauper idiots and imbeciles under 16 years of age remaining to be provided for in addition to the 225 paupers already accommodated in voluntary institutions for the training of imbecile children. Indeed, deducting 52 now resident in the special idiot block of the Northampton County Asylum, there remain but 280, a number insufficient to fill a decent-sized special institution!

Whilst studying the pathological changes met with among those dying insane, I was much struck by the large number of cases in which chronic renal disease of a more or less advanced state was present. This led me to work out, from the post-mortem records of the Somerset and Bath Asylum, the percentage of chronic renal disease noted in such cases. But whilst engaged in these inquiries my attention was especially called to the number of general paralytics presenting this condition, and I proceeded, therefore, to collect all the cases of general paralysis of which the records were sufficiently trustworthy. In this way I collected 75 cases, and of these only nine were free, or apparently free, from renal disease. Of the 66 cases remaining 51 had what must be considered well-marked granular kidneys, and the other 15 had diseased kidneys which were most probably granular, though in a less advanced degree. One of these latter cases had renal calculus. In other words, only in 12 per cent. of the cases were the kidneys apparently healthy, and we may, I think, take it that almost all the remainder (88 per cent.) had granular disease of the kidney. I do not suggest that this is the usual percentage, but among the cases of one asylum it is sufficiently remarkable.

In dealing with insane patients the question of forcible feeding comes up for consideration very frequently. It embraces various points of great interest and importance, on each of which much could be said; but in the present paper I wish to confine myself to some short remarks under the following heads:—(1) The Methods of Forcible Feeding; (2) Feeding by the Œsophageal Tube; (8) The Kind of Food used: and (4) A Reference to some Illustrative Cases.

The last time that I had the honour of reading a paper before this Association, I was told with some asperity by one of the subsequent speakers that the subject was not new, and that he himself had dealt with it some years before. It is better, therefore, that I should at once proclaim that the subject that I propose to deal with in the present paper is by no means new. It has been dealt with years ago by a sister Society, and it is dealt with every year by our own Association in our statistical tables. I venture to submit, however, that there is no necessary obligation upon any member of this or of any other learned body to confine his attention to matters that have never been dealt with before. It is not competent, I submit, to any member to draw a line round any department of knowledge, and to cry to all comers “Hands off! This is my preserve, and trespassers will be prosecuted.” Surely if we think, however presumptuously and erroneously, that we can see a way to advance knowledge in any particular direction or by any particular method, we need not be deterred from doing our best by the knowledge that the field we propose to till is not wholly unreclaimed ground, but has already been under cultivation to some extent.

General paralysis of the insane seems to have been first recognized and described by Willis, in 1672. It was fully described and established as a definite disease by Bayle, in 1822. It received its present title from Calmeil, in 1826.

In the spring of 1893 we received from Dr. Mercier an instrument specially devised by that gentleman for the purpose of automatically registering the breaking strain of the human rib. It was accompanied by a letter, in which we were requested to experiment with the instrument on as many cases as possible and furnish him with the result. By that letter we were at the same time informed that he had sent similar instruments round to other asylums with a like supplication, and that he looked for the co-operation of a number of colleagues in enabling him to collect a number of cases sufficient to constitute a foundation for an accurate statistical record—a record which would, among other things, settle once and for all in which varieties of mental disorder it is that we are to look for ribs possessing a low breaking strain.

Dr. Maudsley opened a discussion on “Criminal Responsibility in relation to Insanity,” in the Psychological Section of the Annual Meeting of the British Medical Association, held in London on 1st August, 1895. He said—I cannot help feeling that I am undertaking a task which is likely to be somewhat barren, for there is little to be said that has not been said over and over again, and will, I fear, have to be said over and over again; for, notwithstanding that the legal test has been condemned by eminent judges and that it has no foundation in science, it still flourishes in full vigour.

Passing to the treatment of special classes of patients, Professor Meyer expresses decided opinions, which seem to be somewhat in advance of the general consensus. For instance, at Alt Scherbitz, or in the remoter asylum of Bayreuth, one finds a considerable amount of restraint and special arrangements for the destructive and violent. It is, therefore, necessary to accept certain statements under the following heads as being more personal than representative.

“Set me as a seal upon thine heart, as a seal upon thine arm: for love is strong as death; jealousy is cruel as the grave: the coals thereof are coals of fire, which hath a most vehement flame. Many waters cannot quench love, neither can the floods drown it; if a man would give all the substance of his house for love, it would utterly be contemned.”