Gentlemen,—In now opening the eighth section of this great International Medical Congress, and in offering to the alienists of Europe and America our cordial welcome to London, I must ask leave to explain to you that it is only by the accident of official position as senior physician to the Lord Chancellor, who, under the Royal prerogative and by statute, has in England the guardianship of all lunatics and persons of unsound mind, that I occupy to-day this presidential chair. But for the desire of the Executive Committee thus to recognise the paramount authority of the Lord Chancellor in our department of medicine, I cannot doubt that the place I now fill would have been allotted to our most distinguished English writer on lunacy, Dr. J. C. Bucknill, one of the vice-presidents of this Congress, whose writings and whose name are a household word in all the asylums where the English tongue is spoken. Called from my official position rather than from personal fitness to preside in this section, I may the more venture to ask at your hands a generous interpretation of my efforts, so to guide your deliberations here that they may advance the science and practice of this department of medicine in which we are all enrolled.

The pulse-tracing in general paralysis has never been thoroughly investigated, and although the tracing said to be characteristic of this affection has been figured and described in several works, I have looked in vain for those records of the amount of arterial tension as estimated by the pressure gauge, without which a mere pulse-tracing is of little reliance and value. I have therefore endeavoured to supply in part this want by a detailed account of the sphygmograms taken in about forty cases of general paralysis, with records of tension measurement and occlusion pressure, the latter taken by Dr. Handfield Jones' sphygmometer, which registers a pressure of 20 up to 600 grammes. The tracings have been all taken, by means of a very perfect sphygmograph, upon smoked enamelled paper, and every source of fallacy which could possibly be eliminated was very carefully excluded.

The subject of moral insanity has already been considered from several points of view, but I think that when typical cases occur it is well to record them, so that, by a careful examination of published cases, more general information may be obtained concerning this malady. It may seem to the philosopher rather a mistaken way of considering the mind to divide it into intellectual and moral, but we in asylums have constantly to take notice of cases in which the moral side of the patient suffers very much more than the intellectual; and though I should not deem any person capable of being intellectually complete and yet morally defective, I would maintain that the defect on the intellectual side may be so little appreciated, or of so little importance in reference to the individual's relationships with the outer world, that it may be disregarded. In considering the cases at present under notice we shall have to point out that most of them have undoubtedly some defect or excess, if I may use the term, in their intellectual processes. When I say excess I refer to the presence of hallucinations and false perceptions that frequently occur in such cases. In attempting to define moral insanity it is easier to describe what it is not than to come to a comprehensive definition which will include all the cases falling into this group, and no others; and, by way of clearing up the condition, I would say that I look upon the moral relationships, so called, of the individual, as among the highest of his mental possessions, that long after the evolution of the mere organic lower parts, the moral side of man developed; that the recognition of property and of right in property developed with the appreciation of the value of human life, so that the control of one's passions, and of one's desires for possession, and of one's passion for power developed quite late in man, and, as might be expected, the last and highest acquisitions are those which are lost most readily. It is frequently noticed that in cases in which slow progressive nervous change takes place the moral relationships are the first, or among the first, to be affected; and in the same way after an intellectual storm it is no uncommon thing to see the intellect partly restored to its normal equilibrium, but still wanting the highest and most humane of its attributes—high moral control; so in the emotional states of acute mania, of general paralysis, or of chronic insanity we have corresponding defects in this highest intellectual control. From this point we shall have to notice moral insanity, it being in many cases a state or stage of mental disease, and not a fixed or permanent condition itself; so that in very many, if not in all, acute cases of insanity there is a period of moral perversion, just as in nearly all such cases there is a period of mental depression. I hardly think it worth my while to make very elaborate distinctions between the varieties of moral insanity. I would take it for granted that all admit what I have already said—that there is a condition in which the moral nature or the moral side of the character is affected greatly in excess of the intellectual side—and I will take the opportunity in this paper of discussing in detail a few of such cases, leaving for myself at another time, or for others, the consideration of cases bearing on the other parts of the subject. I should say that the cases of moral insanity are best considered under the heads of “primary” or “secondary,” and when speaking of “primary” I would refer to those cases which, from the first development, have some peculiarity or eccentricity of character exhibited purely on their social side. Such cases may be divided into the morally eccentric and the truly insane. The eccentric person who neglects his relationship to his fellow men and to the society and social position into which he was born must be looked upon as morally insane. Other cases seem from infancy prone to wickedness, and I would most emphatically state my belief that very many so-called spoiled children are nothing more nor less than children who are morally of unsound mind, and that the spoiled child owes quite as much to his inheritance as to his education. In many cases, doubtless, the parent who begets a nervous child is very likely to further spoil such child by bad or unsuitable education. In considering these latter cases—those that from childhood show some peculiarity of temper and character—it is all-important to remember that inheritance of neurosis plays a very prominent part indeed—that, in fact, the inheritance of neurosis may mean that the children are naturally unstable and unfitted to control their lower natures; that they come into the world unfitted to suit themselves to their surroundings; and, but for the conventional states of society, would soon lose their places and become exterminated. We shall, later, consider cases of this kind more in detail, but I would state before leaving the subject of primary moral insanity as seen in children, that I have seen a state of this kind occur in children of parents who have suffered from some febrile disease, or some constitutional disease like syphilis, before the begetting of the morally insane child, and I have no doubt that more will be discovered in time as to the relationship between the health of the parent at the time of the begetting and the moral state of the offspring.

At the last meeting of this Association, it was seen that great discrepancy of opinion existed as to the value of tables of causation in insanity. On the one hand they were regarded as of the first importance; and on this ground a plea was put forward for unanimity in the mode of tabulation. On the other hand they were looked on as worthless, or almost so; and some applause followed when they were characterised as rubbish heaps.

In the following cases, visual or auditory hallucinations, or both, were more or less vivid and persistent. First the visual, and then the auditory, will be considered, together with the lesions of the respective supposed cortical centres.

In the human subject, strictly limited traumatic brain-lesions are among the pathological conditions which bear most clearly upon the problems of cerebral localisation. Necessarily these accidental experiments upon the human brain are sometimes as sharply localised as are the experiments of the physiologist upon the brains of lower animals. For the purposes of the physician, indeed, they are more instructive than the latter.

Most of us are in the active discharge of the duties of medical attendance on the insane, many of us are at the head of large public institutions. We are by the public expected both to be learned, ready and exact. Serious calls are daily made on our knowledge of medicine and surgery, but by many of us I am certain these are much more readily responded to than the calls on our powers of administration and on our judicial functions as guardians and care-takers, as well as the physician and friend of our patient. Now to my mind no one portion of duty is more unpleasant than having to listen to complaints of illtreatment, or even negligence and carelessness made by patients, to investigate them, to weigh, balance and decide on the best course of action.

When the doctrine of Insanity emerged from its primitive condition of a belief in demoniacal possession, a belief highly spiritualistic in form, and highly materialistic in fact, it became re-moulded in the current forms of thought, and assumed a shape much like that which now obtains among the uninstructed. The concept of mind having attained to but a low degree of differentiation, and the boundaries between mental and material processes being but vaguely defined, alienism in its early stages could not but reflect the imperfections of the knowledge upon which it was compelled to rest. The alienist, observing that his own actions were preceded or accompanied by mental processes, that the more pronounced his actions the more vivid the feeling which accompanied them, that from each action he could trace backward the line of thought which prompted it; and being generally impressed with the close interconnection between his mental states and his conduct; looked at them as in the relation of cause and effect, and shared the then prevailing doctrine that the Mind, by means of that portion or faculty called the Will, directly produced the bodily actions, much as the force stored in the mainspring of a watch produces the movements of the hands.

The hallucinations of the senses in the insane resemble the voluntarily induced semi-consciousness of the mesmerised. In the mesmeric trance there is the disregard of external agencies that is seen in the maniac who, regardless of suggestions from without, carries out his own wild train of thought in apparent unconsciousness of what is going on around him, or even memory of what has occurred to him, after the trance or the paroxysm has passed away—and so in sleep, dreams prove an active state of the cerebral centres, although no recollection of them may remain on awaking. Sleep has been likened to temporary death, and so dreaming may be compared to temporary insanity. The insane man walks about in a waking dream; he is a veritable somnambulist. The somnambulist, like the maniac, or the ecstatic, has but a confused recollection, or no remembrance at all of what has occurred in the attack of mental disorder, or in their perilous sleeping performances, like Fakirs in their trance-like condition, they become insensible to external influences.

The education of the imbecile is an enterprise the inception of which dates from a very recent period. The generation has not yet passed away, which frankly insinuated that the idea of teaching the idiot could only enter the brain of one somewhat closely related to the class. It is now everywhere recognised as an important and imperative duty which cannot be neglected without shame and loss; yet for efficient practical effort, it is still but the day of small things.

Before the circulation of the blood was discovered, the pathology of diseases of the heart must have been unknown, and their treatment empirical and of little effect. Before the discovery of the glycogenic function of the liver, the pathology of diabetes remained a mystery, and its treatment a matter of guess-work. In all dealings with the facts of life, the science of the normal must precede the science of the abnormal. In the domain of mental operations the science of the normal is of very modern discovery, and Alienism, the science of the abnormal, has consequently been until recently compelled to limit itself to collections of materials for future use, and to tentative groupings of these materials which have necessarily been provisional on their harmonizing with the future developments of the science.

Four centuries ago, by his celebrated Bull proclaiming death without mercy against witches, sorcerers, and all dealers with Satan, Pope Innocent VIII. plunged Europe into a state of social distraction and delirium. One half of the people were said to be bewitching or bewitched. The crime of witchcraft or devil-dealing—a token of heresy—was held to be the precursor of antichrist, and there was no lack of propitiatory sacrifice. “The seats destined for criminals in our courts of justice are blackened with persons accused of this guilt. There are not judges enough to try them. Our dungeons are gorged with them. No day passes that we do not render our tribunals bloody by the dooms which we pronounce, or in which we do not return to our house discountenanced and terrified at the horrible words we have heard. And the devil is accounted so good a master that we cannot commit so great a number of his slaves to the flames but what there shall arise from their ashes a sufficient number to supply their place.” So says Florimond, the historical mouthpiece of the time. In Germany they burned them at the rate of 500 a year, bringing the total for the whole period of persecution for witchcraft up to more than 100,000 human beings. It is said that in France, about the year 1520, fires for the execution of witches blazed in every town. People had to be busy smelling Satan in others lest they themselves should be suspected and taken in hand.

There occasionally occurs in lunatics who are labouring under acute maniacal excitement a more or less rapid loss of power. This may be followed by no further consequences; sometimes it marks the beginning of recovery, but it may rapidly end in death.

Hypertrophy of the Brain is a comparatively rare disease, and has attracted little notice in England. Laennec first drew attention to its occurrence in children, and to its similarity to chronic hydrocephalus in many of its symptoms, and the likelihood of its being mistaken for it. The cause of the disease is obscure. Brunet defines it “as an increase in the weight of the organ due to a disorder of nutrition, leading to an alteration in the nervous “substance.” The process is not one of mere increased growth, but the nutrition of the organ is modified in character as well as increased in activity. According to Rokitansky the augmented bulk is not produced by the development of new fibrils, or by the enlargement of those already existing, but by an increase in the intermediate granular matter, most probably due to an albuminoid infiltration of that structure. My own observations lead me also to the opinion that the disease, as seen in imbeciles, is due to an increase in what appears to be granular matter, for in some sections, which I have in my possession, this is seen. The change is accompanied by an increase in the number of the blood vessels, and the presence of a large number of leucocytes. Andral states that in two post-mortems made by himself, the white matter resembled the white of egg hardened by boiling. In one post-mortem only have I noticed any peculiarity in the white matter, and in that case I find I have recorded that it was of a “peculiar whiteness.” The parts affected are chiefly the white matter of the two hemispheres, sometimes the corpus striatum and optic thalamus, rarely the pons and cerebellum. MM. d'Espine and Picot consider the affection to be a congenital one, and in this opinion I concur. They hold, however, that imbecility only results when hypertrophy of the brain is accompanied by sclerosis. My experience does not lead me to this opinion, for in none of the seven post-mortems which I have made was sclerosis present. Brunet, too, describes two cases of hypertrophy of the brain without sclerosis which he has seen in idiots. Both d'Espine and Picot and Brunet describe two forms of the disease; in the one the hypertrophy is simple, in the other accompanied by sclerosis. The principal symptoms are headache, at times intensified, excitement followed by coma, blunting or arrest of development of the intelligence, difficulty in walking, and convulsions. The symptoms are said to be less marked in children than adults, because the brain is less compressed, the cranial cavity increasing in size as the brain enlarges. I proceed to relate particulars of some cases which have come under my observation.

To recognise disorder of the mind in its early phases, places it within our reach at the most opportune season for checking or arresting its progress. The first signs of alienation, if duly appreciated, should afford warnings to have recourse, without delay, to the means of cutting it short. The consequences of overlooking or neglecting these timely indications may soon become irreparable. With what thankfulness do we not hail prevention in malignant or infectious maladies; with equal eagerness ought we not also to be on the watch for, and ready to avail ourselves of, means of staying the approach of symptoms that may apparently be less urgent or less obvious, but which are nevertheless certain indications of an affliction which may blight the hopes of a whole life, bringing with it unhappiness and misery incalculable.

During the autumn of last year I had occasion to visit the parish of Minto, in Roxburghshire, and on making enquiries as to the history of a certain patient, W. N., who was about to be sent to the asylum at Melrose, where I held the position of assistant medical officer, I was told that he was one of seven children who were imbecile, out of a family of eleven, and that the father of this family was popularly supposed to be not altogether right in mind. Thinking that if I followed up this case it might prove to be of some interest, I determined to investigate it.

After a brief reference to the frequency of hallucinations in general paralysis they will, in the second place, be considered in relation to the question of cerebral localization.