In examining the male cases admitted to the Richmond Asylum during the year 1907, special attention was paid to the mixed variety of maniacal-depressive insanity as described by Kraepelin. The result, I must say, was disappointing, for out of 292 admissions only one case came under this head. It is only right to state that fifty-five of these cases were drafted to the Portrane Auxiliary Asylum, where I was unable to follow their history. Of these 292 cases 42 were suffering from acute mania and 59 from acute melancholia, and neglecting the cases sent to Portrane, none of these, with the one exception, departed from the ordinary course of these diseases.

This paper is an answer to a challenge thrown down by Dr. Urquhart on the occasion of the Annual Meeting of this Association in 1905, when I had the honour of reading a short description of the small hospital we were then opening in Brighton and its raison d'être.

Let me first explain or define the terms used in the title of this paper. By “hospital treatment” I mean treatment in any institution where patients have to be treated in numbers together, and where it is possible to have efficient nursing. My remarks, however, will have special reference to county and borough asylums as they exist at present. By the “acutely insane” I mean those patients who are suffering from insanity which has begun at a recent date, and which we may hope to relieve.

While acting as Assistant Medical Officer in the London County Asylum at Horton, Epsom (1907–1908), I made an investigation into the head measurements of the various classes of male lunatics, contrasting these with their bodily height and weight.

The lectures of Prof. Kraepelin, as presented to us in Dr. Johnstone's excellent translation, form a fascinating study. Yet it is probable that with respect to some of them a reader is apt to rise from their perusal with a certain amount of mental confusion. His descriptions, from a clinical standpoint, are delightful reading, and lucid in the highest degree; but when, with the help of new terms, which really only express old familiar facts up to this otherwise expressed, he casts into new groupings cases which have two or three features in common, although differing considerably in their course and in the varying phases of mental disturbance which they present, there is a difficulty in following him. And any scheme of classification founded on a more or less casual and fortuitous similarity as far as a few symptoms are concerned, while ignoring important points of difference, cannot do anything else than create confusion. No doubt Kraepelin's object, so far as we can judge of it, is to group cases of insanity in such a way as to constitute a real help to diagnosis, and, what is of more importance, to prognosis, in the multitudinous phases of mental derangement which come under our notice, and this object is, so far, a meritorious one. But is the object attained by this method? Is it attainable? The fallacy—for it is nothing else but a fallacy—of regarding any mere grouping of symptoms of insanity as a distinct disease entity is apparent throughout. Insanity is protean in its manifestations, and the symptoms in any particular case may at one point of its course resemble those of one of the so-called varieties, and at another they may correspond with those of quite a different grouping. This fact alone would seem to indicate the futility and uselessness of founding any system of classification of insanity on symptomatology. The endeavour to do so can only be regarded as an impossible feat, a feat which is nevertheless being constantly attempted with a persistent fondness which is quite pathetic by most classifiers, who seem anxious to rival the punitive labours of Sisyphus or the daughters of Danaus, with similar fruitless results.

In confining the following remarks more particularly to a personal experience, I trust I shall not appear unconscious of the more able treatment the subjects of this paper have received at the hands of more experienced observers.

The recent Royal Commission on the Care and Control of the Feeble Minded was occupied with two main subjects of inquiry. First, the existing methods of dealing with idiots and epileptics, and with imbecile, feeble-minded or defective persons not certified under the Lunacy Laws. Second, the constitution, jurisdiction and working of the Commission in Lunacy, and other Lunacy Authorities. The Commissioners were requested also to report on any amendment of the law which should appear desirable in relation to these subjects.

The enormous importance of the disease under consideration is, I am sure, not adequately realised, and it is for this reason that I am particularly desirous of bringing the subject to the notice of members of the Medico-Psychological Association. In my opinion the status lymphaticus constitutes one of the most serious problems of medical science at the present time, especially in these days of deaths under anæsthetics.

The subject of the experiences about to be described is a literary man of great ability and a recognised authority in a certain department of learning, who had unfortunately been addicted to the abuse of alcohol for many years and had decided to try the effects of a course of atropin treatment. He was perfectly sane. Previous to his admission he had been practically living on milk and whisky for a considerable time, taking five or six glasses of the latter in the day. The whisky was at once greatly reduced, though not altogether stopped; and combined injections of atropin and strychnine were begun on the day of his admission (November 22nd), with dietetic and other treatment, but no sleeping draught was given either that night or the next. This was the first case which I had treated by the atropin method, and I should not now commence the injections so soon after admission. No other case, of a good many since treated, has suffered from hallucinations, but they have often been met with by others.

Before submitting to you my ideas on the much-disputed question of dementia præcox, there are one or two points in the papers of Drs. Jones and Urquhart to which I should wish to draw attention. I will take them in the order in which they occur.

When the Australasian Medical Congress met in Melbourne, in 1889, I dealt with “The Housing of the Insane in Victoria, with Special Relation to the Boarding-out System of Treatment.” Since then I have had ample opportunity of satisfying myself that such a method of caring for and treating the harmless insane is not suited to our colonial life. Much personal attention was given to this matter, and I was not satisfied with the results, the majority of the patients being in the care of officials of the various hospitals practically as servants. This was given a trial, as the official staff were practically the only applicants, not that I believed in the advisability of granting them patients. I ceased doing so, because it was evident the cases were taken for what could be got out of them, a circumstance which existed also with other applicants. This method of caring for our accumulated insane population being demonstrated unsuitable, we perforce fell back upon institutional accommodation for the chronic harmless cases.

It is indeed a true saying that to be successful in the treatment of disease clinical observation must be accompanied by biological and bio-chemical research. Yet the practice of medicine in times not so very remote was chiefly based on careful observation and common sense. In by far the majority of diseases the ætiology was not understood, and this was strikingly true of the acute forms of mental derangement. Still, devoted workers and searchers after truth continued their investigations on the dead and their experiments on the living. Gradually appliances were improved and new methods pursued, and with such brilliant results that at last the true cause of infective disease was discovered. One by one bacteria were isolated and studied, and thus a great world of medical research was opened out and results obtained which have already wrought untold blessings to humanity.

The use of Receiving Houses, that is to say, houses established specially for the observation of doubtful cases of mental disorder, is almost entirely of Australian origin, although something analogous exists, and has existed for many years in England and Scotland, in the Lunacy Wards attached to the Workhouses, Infirmaries, and Poor Houses. The latter, however, do not fulfil all the uses that the Receiving House can be put to; neither are they independent institutions, nor do the terms for which patients can be received correspond.

One cannot visit the wards of an asylum without realising that there are many types of mental disease, each with its own symptoms and physical signs, and that intercurrent and overlapping affections of the mind are especially common; thus, in maniacal excitement you may find delusions, in paranoia you find delusions with marked impairment of judgment, in general paralysis you get, in addition to physical signs, delusions, which vary from the facility of the early period to the more difficult mentation found in the advanced age, so that here we have three distinct types of disease, each of which may have delusions, and the delusions may all be of the exalted variety— the patients may consider themselves gods, kings, or mighty personages. The progress of research has had more difficulties to contend with in the subject of mind than in almost any other. It is a subject which is intangible, yet its reactions can be timed. It is unseen, yet its force can manifest itself in various ways through various channels, and it is even possible to transfer it from one person to another if the medium is so constituted, as in hypnotism, thought transference, and similar phenomena. It may occur to you to ask why has the subject of insane movement and obsession been chosen for this paper; well, gentlemen, for some years it has been my lot to witness, on my daily round of the wards, grotesque movements, antics and pantomimic display by patients, which, were they not interesting as symptoms and physical signs of nervous disease, might otherwise be depressing because of their meaninglessness. About three years ago, however, I had my attention drawn to a woman who seemed engaged in making movements, the precise character of which I had not read of or seen before in any asylum. I shall show you this patient making these movements by means of the cinematograph. We would have brought her here only she obstinately refuses to operate when watched, and it was necessary to have the cinematograph pictures focussed through a partly open window when she least suspected observation. Gentlemen, we are well acquainted with such terms as insane acts, insane expression, insane language, insane conduct, and insane movements.