In choosing a subject for this address, I have felt at liberty to go outside the boundary of psychiatry, and I propose to put before you a slight sketch of the present position in clinical psychology. First, it is necessary to explain what I intend to denote by this term. It may be said that there is not and cannot be any branch or section of psychology that can properly be so called; for the clinician necessarily deals with his patient as an entire organism, and cannot, in considering his mental life, abstract from any one part or function of the mind to concentrate his attention upon another; his psychology therefore must be concrete and must deal with the mind as a whole. This is true, and it follows from this truth that, when our knowledge of the human mind shall have become an adequate and well-established science, that science must be the theoretic basis for all who are practically concerned with the working of the mind, whether they are chiefly and immediately concerned with the normal mind or with minds in disorder.

The theme of the address I am about to give—if anything so discursive can be said to have a theme—is the medical treatment of the insane during the period of transition and reform at the end of the eighteenth and beginning of the nineteenth centuries.

[The following article was sent to the Editors so far back as the autumn of 1916. Exception was taken by the Censor to certain passages, and as it was felt that it was preferable that it should be published in its entirety or not at all, its publication was withheld in the hope that the objections would eventually be withdrawn. This has now been done, and the Editors are glad to be in a position to present the article as it came from the pen of Dr. Maudsley, and without any mutilation.

During the period from March 1st, 1918, to January 11th, 1919, the writer held the appointment of Mental Specialist to Boulogne Base, and was in charge of the mental wards for that area. These were located at No. 8 Stationary Hospital at Wimereux, and received all the mental cases developing in or brought to the Boulogne and Calais areas. In addition a number of cases were sent for report from the local standing medical board, and many cases were seen at other hospitals.

That there is some relationship between goitre and the psychoses is beyond all question. We have only to recall the mental syndromes of Graves' disease and endemic cretinism—goitre occurs in all but a few exceptional cases of the former, and in about 50 per cent, of the latter. Moreover it is by no means uncommon to find goitre in adult myxcedema.

The distinctive signs and symptoms of neurasthenia are capable of fairly precise definition, and there need rarely be any doubt, or difference of opinion, as to whether a particular case is to be classed as of this nature or not. The chief symptoms are a constant feeling of fatigue, not relieved by rest, and the occurrence of various forms of hyperæsthesia, paræsthesia, and localised pain. Two important physical signs constantly occur—exaggeration of the patellar reflex and tremor of the eyelids when the eyes are half closed. Added to these, there are, in greater or less degree, characteristic mental features which constitute the picture of psychasthenia, namely, incoercible ideas, obsessions, and monophobias.

An article under the title of “The ætiology of Crime” by Dr. Goring, in the April number of the Journal for 1918, consists to a great extent of criticisms of one by me, entitled “Notes on Mental Defect in Criminals,” which appeared in the January number for 1917, and contained special comments on Dr. Goring's well-known work “The English Convict: a Statistical Study.” As it then seemed to me necessary to consider Dr. Goring's views when writing on this subject, it seems equally necessary now to make some comment on his criticisms. The main reason for the following remarks is the interest and importance of the subject-matter on which he and I differ; but since some of his strictures depend greatly on misrepresentations of what I have written, or on imputations of arguments and opinions that I have not uttered, I am forced to occupy more space in this paper than I could have wished in quoting from Dr. Goring's charges and re-stating my own position.

The fluid obtained by the easy and now frequent procedure of lumbar puncture affords, when subjected to simple tests, valuable aid in the diagnosis of mental disease.

The question of a combined arts and medical curriculum has long been a source of dissension among the authorities of our universities, and it is my intention in these pages to lay emphasis on the enormous value of a modified arts course to students of medicine. The average student looks on the enforced study of arts askance, and regards the accompanying lectures and examinations as the deliberate attempt of a malevolent professorial hierarchy to wreck his scientific career; but in later life, when he finds himself thrust upon his own resources with education and common-sense to guide him, he unconsciously begins to reap the benefit of his B.A. degree.

Mr. President, Ladies and Gentlemen,—Probably most of what I shall say to you this afternoon will be well known to you; indeed, many of you may think the information self-evident and trivial, but in spite of this I hope that what I say may serve to re-emphasise in your minds the fact that we are all very subject to our environment.

At the present time, to investigate fully the psychoses of those in military service would necessitate an inquiry into the mental health of the male moiety of the entire British nation. Admitting the truism that the war has not produced any new form of mental disease, it is nevertheless interesting to bring forward and accentuate the differences and similarities found in psychiatric military and civil institutional practice.

Men and women hold to and have faith in certain opinions as the result of long thinking around and along certain lines. Our social and political tendencies are the outcome of an analysis more or less critical, and believed by the individual to be impartial. A scattered phrase or an apparently insignificant incident may attract attention, and be the beginning of a prolonged mental conflict which is finally determined by a definite line of thought. It does not follow that the reasoning is always logical, or the argument conclusive to people of other opinions, but nevertheless a conclusion is arrived at, and it is final.

The demonstration by Noguchi and many other investigators after him of spirochætes in the nervous texture in tabes dorsalis and in dementia paralytica has, as is well known, quite subverted the old conception of these diseases as para- or metasyphilitic in nature. They are just as syphilitic as other diseases caused by Spirochóta pallida are. It is quite a different thing, however, that in certain respects they occupy a peculiar position; as a rule they do not manifest themselves till ten to fifteen years after the primary affection, and they are very little affected by antisyphilitic treatment. It is well known that it was especially this last fact which caused them to be considered as not syphilitic in the common sense.

Mr. President and Gentlemen,—You will, I know, agree with me that there is no doctor who has not frequently been at a loss to know what treatment to adopt in a case which, although apparently simple and straightforward, continued to show no signs of improvement, and when we are dealing with mental cases this is, I think, especially noticeable. But, after all, we must admit that the means at our disposal for the treatment of mental diseases are very inadequate—differing widely from many medical and surgical conditions in which the only and proper treatment is invariably followed by recovery. In most mental diseases I am afraid we must acknowledge that there is still no specific treatment guaranteed to cure any given case: recoveries frequently occur when least we expect them, cases which we deem recoverable frequently disappoint us.

A Sub-Committee of the Parliamentary Committee of the Association was appointed in January, 1918, the terms of the reference being “to consider the amendment of the existing Lunacy Laws.”

In many respects the difficulties of administration are greater in hospitals and private institutions than in public asylums maintained out of the rates. The financial problems raised by the reduction of hours and the increase in salaries, as well as the greater cost of all commodities, are very serious when there is little prospect of increasing the income to meet the increasing expenditure. What will happen if the present tendency continues no one can foresee, but it seems quite clear that the middle classes will soon be unable to bear additional burdens. Already many patients with limited income cannot possibly pay increased charges, and it would be cruel to discharge, for financial reasons, aged patients who have been under care for years, and have no other home than the asylum in which they live.

Special features of interest in two cases of epilepsy in twin sisters under care in this asylum induced me to publish these short notes, although the cases do not exhibit anything particular from the clinical side.