Numerous observations have lately been recorded in medical literature on the acute manifestations of epidemic encephalitis; but the late after-effects, especially those of a psychotic nature, have been seldom described. Kirby and Davis (1) have emphasized this, and have recorded 18 cases in their early and later stages. They remark that “a satisfactory solution of certain of the psychiatric problems presented by this disease will require a longer period for clinical observation of cases than has elapsed since the appearance of the epidemic of 1918–19.” The following series of 10 cases is offered as a contribution to the clinical records of the sequelae of the disease, especially from the psychiatric point of view. Eight of them originated in connection with the epidemic of 1918–20. The remaining two are of remoter origin, and are admitted on account of their close resemblance to the others, and of their special interest from the point of view of classification and prognosis. Five of them (3, 5, 6, 9 and 10) are, or have been, in mental hospitals. In this connection the only statistics available to me are those quoted by Kirby and Davis (loc. cit.) for the New York State Hospitals in the hospital year from July 1, 1919, to June 30, 1920, when, out of 6,500 admissions, only 20 were considered to be probably cases of epidemic encephalitis. (But the epidemic was subsiding at that time.) The 5 cases mentioned should therefore be of considerable interest; and it is one of the purposes of this paper to show that a more thorough knowledge of the results of this protean disease would lead to its being diagnosed more frequently among the cases, even those of very long residence, in mental hospitals.

By the death of Dr. Alfred Miller, Medical Superintendent of the Warwickshire County Mental Hospital, the medical profession of Warwickshire, the Warwick County Mental Hospital, and the Medico-Psychological Association of Great Britain and Ireland have sustained a great loss.

There is great difficulty in finding a novel theme as the subject of an address to the members of an Association which rejoices in the maturity of its eighty-third year of existence. Still greater is the difficulty in finding a subject of common interest having regard to the varied branches of work covered by their labours, ranging as they do from the busy routine of a crowded day to the silent special research in the laboratory. And the greatest difficulty of all lies in the fact that in each of these fields of work there are many present who have had vastly wider opportunities than I have had, and who could treat their chosen subject with infinitely more skill in thought and language than I can command. Since, however, you have been good enough to give me the opportunity of addressing you I feel you will be no less generous in pardoning my shortcomings on this occasion.

The subject which I intend to bring before you to-day mainly relates to the thyroid gland, a part of endocrinology I have been interested in for some time past.

The diagnosis of dysentery is a matter of considerable administrative importance in mental hospitals.

The organization of the study of psychiatry and neurology at the Universities in Holland has been very difficult. Schreuder van der Kolk, the well-known reformer of psychiatry in my country, was Professor of Physiology at the University of Utrecht. The fruit of his work was the asylum of Meerenberg, exemplary at that time, very useful still, but he did not organize medical education in psychiatry. He died in 1862. It was not until 1871 that our “Society of Psychiatry” was constituted. The many petitions originating from this society brought about the first possibility of psychiatrical teaching by our “law on higher education,” of 1877. The director of the asylum in Utrecht, Dr. Van der Lith, got the title of a university professor. His lectures were not obligatory, and he retired in 1878. In Amsterdam an energetic young doctor, Arie de Jong, taught psychiatry from 1878 to 1881. When he retired psychiatrical teaching was no longer given in Holland. Organization of this branch of medical education had never existed. Examination in it did not exist. Asylum doctors were mostly recruited from military medical men, returned from our colonies, who desired to add the small pay of the asylum to their pension.

Mental after-care, since the establishment of the Association bearing this name more than forty years ago by Mr. Hawkins the then Chaplain of Colney Hatch, has become very generally adopted in most countries.

To ask this question is not to throw discredit on the great work that Prof. Kraepelin has done for psychiatry. Indeed, the opinion may be frankly recorded that no conception dealing with mental disease advocated during the last fifty years has been more fruitful of beneficial results than that of dementia praecox. Out of a symptomatology which before had been more or less chaotic and disheartening Kraepelin evolved a scheme which, if it did not introduce perfect order, certainly marked a very great advance. And not the least of the benefits that psychiatry has derived from him, has been the greater accuracy of observation that his views have enforced upon all clinicians who desire to make an exact diagnosis or prognosis.

The period of childhood which precedes puberty and lasts about three years is one in which growth, both physical and mental, is slower than at any time until near complete maturity. The child has reached a point of stability, and of almost complete adaptation to its environment. The dawn to the full development of the function of reproduction occupies four to five years, and during this period, and coincident with the formation of the secondary bodily sexual characters, there is a complete mental revolution peculiar to each sex.

There is probably no disease in regard to which our views have undergone so radical a change during the past few years as general paralysis of the insane, and none in which the discovery of the causative agent has been followed by so rapid a revolution in standpoint. Although almost from the time of its definition, more than a century ago, the essentially organic nature of the disease and its close relationship to syphilis have been universally recognized, it has required many years of patient study to free it from the hypotheses which have been invoked to explain its obscurities, and, as always happens in scientific progress, in the process of unravelling the knotty problems of this disease, we discover that there are new obstacles and difficulties to be overcome. Is the Spirochóte pallida alone responsible for the genesis of general paralysis? When does it gain access to the nervous system, and how? Is there a special strain of spirochóte, or must the individual resistance of the infected person be considered the deciding factor in the development of the disease? What is the meaning of the long latent interval before the onset of symptoms? What determines the peculiar distribution of the lesions in general paralysis, and is there some particular place in the brain from which the spirochæte starts its wandering? What is the significance of the absence of spirochætes in other organs of the body, and why does the cerebro-spinal fluid contain no organisms at a time when the brain contains millions? Why do tabes, general paralysis and optic atrophy, supposedly of similar origin, not occur in conjunction more frequently? Why is it that arsenical compounds fail to effect a cure?

There is a type of social psychology which finds the explanation of man's social behaviour in a hypothetical “disposition” of his mind. This motive-complex is conceived as specialized for the function of adapting conduct to social life, and as being in itself relatively closely integrated, developing and functioning as a whole. Of this hypothetical “gregarious instinct” McDougall goes so far as to say: “For it is highly probable that instinctive dispositions are Mendelian units” (Journ of Abn. Psych, and Soc. Psych., vol. xvi, p. 316). This plainly suggests that the unity of the social disposition (its existence as a discrete factor in development) is to be regarded as antedating experience—that it is an ultimate datum for psychology not susceptible to analysis, and is not a derivative of any other known motive such as “love,” “fear,” or “hope of reward.” This “instinct” interpretation of social behaviour has been criticized on many grounds (as unfruitful for psychology and incompatible with biological fact); but of course the demonstration of a Mendelian transmission of the social disposition would compel us to regard it as an element of character. Our conception of mental development and of the “socialization” of the individual, of the relative significance of upbringing as compared with organic endowment and our whole psycho-pathology depend upon our acceptance or rejection of McDougall's view. If he is right in regard to the germinal “unit” determination of the social disposition, criminological studies should offer verification. I propose, therefore, to consider how far we are justified in regarding moral insanity and moral imbecility as true “morbid entities.”

The puncture of the cisterna magna was proposed and carried out in 1919 by Wegeforth, Ayer and Essick, who performed a series of experiments on animals before applying the method to man.

In the last few years a vast amount of research has been carried out on dementia præcox.

Metabolism means the chemical changes of materials under the influence of living cells, and basal metabolism as the rate of energy exchange during rest when only the essential vital processes of the body are at work.

It is some eight or ten weeks ago since I had the privilege of enjoying the hospitality of your genial secretary, and in an unguarded moment, doubtless stimulated by my host's genial company, I half committed myself to giving a further communication on this subject, and he committed me for the other half. The truth is I have no paper to read. I have very little further to add to what I have said before, and I have certainly nothing further of note worth publishing. At the same time I very gladly welcome the opportunity of reviewing the position, so far as it appears to me in the light of the further available records on the subject in the last two years.

A cursory survey of the varied fields of human activity suffices to establish the existence of a fundamental rhythm, an action and reaction, an antithetical sequence as it were, by virtue of which the prevailing phase in any movement is inevitably and inexorably succeeded by its direct opposite. Manifestations of this periodicity or cyclical tendency underlying all forms of human endeavour abound on every hand. Peace follows war as night succeeds day; an age of feudalism and despotic rule gives place to one of democratic Government. The time-worn creeds and simple faiths crumble a little before the exigent demands of a higher criticism, and, even as we glow with triumph at the achievements of modern science, we feel the premonitions of new developments whose exponents care for none of those things, and speak not the language of an out-worn materialism. And here it may not be inapposite to remark that the science of medicine is by no means immune from this prevailing principle.

This completes a résumé of the chief changes made in twenty-eight years. It was an unsuccessful attempt to manage a high admission-rate, no longer considerably helped by a high death-rate, in establishments not sufficient to deal with even a quarter of the admissions. Persistent overcrowding only palliated the excessive discharge of patients, and produced great difficulties in administration. The occupation of the dining rooms and corridors by beds prevented ordinary convenience. A high accident-rate and a low recovery-rate were inevitable results of the overcrowding. We were often forced to admit over a thousand cases a year, and to discharge as many, less the number of deaths. Meanwhile these discharged cases committed crimes, and we were continually incurring criticism for our actions. Whenever an extension of accommodation was granted, it was so small, and it took so long to provide, that on its completion it was swamped at once, and the overcrowding was but little relieved. Besides managing the Hospital, one had to besiege the authorities for funds for buildings, in season and out of season, and to take every opportunity to interest them in the work, and educate them as toits importance. The lack of beds for the insane in Egypt remains grave, while in England there are 8,663 vacancies (vide Blue Book for 1922). In twenty-eight years the number of beds for the insane in Egypt has risen from 300 to 1,841. Thus there are now 14 beds to every 100,000 of population. Compare 250 in England, and 3 in India to every 100,000. It is still seldom possible in Egypt to treat curable cases until their recovery; thus 527 uncured cases were discharged in 1922, and still only the dangerous and unmanageable can claim hospital treatment.

This subject has caused much discussion among psychiatrists since the presentation of a paper dealing with this matter which was read before the American Psychiatric Association at its annual meeting held in Quebec City in June, 1922.

It is a truism that successful treatment in any branch of medical practice, or, indeed, in a wider sense, in any activity in which we may be engaged, depends on an adequate and exact knowledge of the relation of cause and effect, and the conscientious clinician who bears that fact in mind finds the present position of clinical psychiatry one of great difficulty. As a highly esteemed physician remarked a little while ago—during one of those outbursts of professional candour which seem to be necessary at times in the interest of our self-respect, so far as our capacity to really modify the condition of our patients is concerned, we are in the position of interested observers, for we may arrange conditions, we may guard against added stresses, but do what we will, and however hard our endeavour, our patients alter, some to improve, others to deteriorate, with an aggravating indifference to our efforts. It behoves us, then, to be extremely critical of our assumptions in any particular case, to be as precise and as adequate as possible in our description of the whole train of events, and to review very carefully any deductions we may make as to the relation of possible cause and effect.