Gentlemen,–The coveted position of President of this Association, which is to-day celebrating its sixty-fifth anniversary, is one to which many may aspire but few may reach, and I recognise to the full that the honour of being selected by you as worthy of this office–the highest compliment in your power to bestow–is not due to any distinction or merit in me, but arises from the fact that as your Secretary–holding an office which at least requires assiduity and patience–I have been closely associated for a longer period than has fallen to the lot of any of my predecessors with the interests and objects for which our Association has existed, viz., the promotion and cultivation of science in relation to mental disorder and improvement in the treatment of the insane.

Possibly the title superscribed to this short article may prove misleading; if so, I must crave your indulgence, as the subject to which perhaps such a title is more applicable could scarcely be done justice to within the short limits of time allotted us. I merely wish to skim over the surface of this question of alcoholism and indicate some special features which have appealed to my interest in this connection, prefacing my remarks on the geographical distribution of alcoholism and insanity with a cursory review of the physiological action of alcohol upon heatformation and its effects on those centres presumably operant in muscular sense discrimination.

In the present section the writer proposes to deal at length with the symptomatology, which is the psychic equivalent of those physical states of the cerebrum which are the necessary precursors of dissolution of the cerebral neurones. There being no suitable word in use for the description of this symptomatology, and it not appearing desirable to coin a new one for the purpose, the term “mental confusion” will be employed to connote, in the broadest sense, the mental symptoms which occur in association with certain pathological states of the cortical neurones which may be followed by the recovery or by a more or less extensive dissolution of these elements.

Examples of true hysteria are relatively rare in asylum populations, and in the present series of cases there are but six instances amongst the 728 patients, and all these are of the female sex. The writer has, however, during his asylum experience, seen more than one case of genuine hysteria in the male sex.

The hope that a study of aphasia might show a way to a better understanding of the nature of insanity is not new. Even at a time when far less was known about aphasia than is known to-day such a hope was not without easily conceivable grounds. It will now hardly be maintained that the perverted speech of a lunatic is always to be regarded as a just presentation of perverted thought. Not only is the thought disordered, but often also the speech itself. The symptom of perseveration, for instance, does not always represent morbid prevalence of an idea; it may express a disorder which lies rather within the sphere of speech. This is well illustrated in a case of eclamptic insanity reported by Heilbronner. Of pictures representing birds of various kinds, the patient designated many in succession as “swan,” even when identification was correct; she called a stork a swan, and at the same time alluded to the stork fable. In this instance it is not the idea that clings, but the word, as in the recurring utterances of an aphasic. In many forms of mental disease we meet with symptoms of amnesic aphasia, loss of nouns, inability to name objects seen. In certain forms of incoherence we can recognise an element of paraphasia. Thus we can often obtain a clearer conception of the speech disorder of a lunatic by regarding it from the aphasic standpoint.

The subject of fatigue, rest, and sleep cannot be approached without reference to the theory which has revolutionised our ideas of cerebral activity-the neuron theory of Waldeyer and Ramon y Cajal. This theory is certainly “in the air,” and despite the adverse views of notable histologists such as Apathy, Bethe, Dogiel, Donnagio, and Hill as regards its universal applicability, it has, I think, come to stay with us, as have the cycle, motor, submarine, and probably we may shortly say the aeroplane. Arguments, pro and con., are scarcely called for here, but there are a few points which I cannot omit reference to.

The present and final division of this paper contains a description of those types of mental disease which are classed by the writer under the heading “Dementia.” Under this term he includes all cases which agree, from the psychic aspect, in the possession of a decreased or decreasing mental capacity, and from the physical, in the existence of a distinct and permanent loss of cortical substance in those regions of the cerebrum which especially serve as a physical basis for the carrying on of (voluntary) psychic processes.

The clinical study of the physical symptoms of mental diseases has of late years been pushed with energy and originality, not only in this country but also abroad. Advances in the general knowledge of physiological and pathological chemistry and the great doctrine of immunity have had their effect upon the views held regarding mental diseases, and particularly with regard to their causation.

So much has been written on this subject, that I trust it will not be considered disrespectful to previous observers if I refer more particularly to my own experience and observations. As out-patient physician to Charing Cross Hospital, and latterly physician in charge of wards, I have had a considerable experience in seeing the effects of alcohol in the production of bodily diseases; but as Pathologist to the London County Asylums I have had a much larger experience in seeing the effects of alcohol in the production of mental diseases. I can safely say that in quite one fourth of the male cases which come under my observation at Charing Cross Hospital, and in a considerable proportion of the female cases, alcohol has been an efficient cause in the disease, or a very important coefficient. In conjunction with venereal disease, especially syphilis, it is responsible for many degenerative processes, which will be alluded to. My house-physician, Mr. Reade has kindly made a tabulated statement referring to the influence of alcohol in the medical cases admitted during the year 1905, which is appended.

“The evidence … so strong that the relations of mind and nervous structure are such that the cessation of the one accompanies dissolution of the other, while … with death there lapses both the consciousness of existence and the consciousness of having existed.”

The description of the varieties of dementia which is contained in the present section is based on the clinical classification of 728 cases of mental disease referred to in Part I of the present paper (Journal of Mental Science, April 1905).

As a preface to the remarks which I propose to submit for your consideration to-day, I wish to recall to your memory the substance of a paper which I had the honour to read before this Association some two years ago(1). In that paper I endeavoured to establish a distinction between two opposed types of drinking, which, having regard to the chief factor in each form, I referred to as convivial drinking and industrial drinking; and I pointed out that these two modes of drinking differed widely in their relations to drunkenness and to chronic alcoholism, convivial excess producing drunkenness but rarely tending to cause chronic intoxication, while industrial drinking, on the other hand, though not an immediate cause of drunkenness, led rapidly and fatally to chronic poisoning. And, as an illustration and proof of the reality of this distinction, I drew your attention to the remarkable differences in regional distribution which are apparent when drunkenness is compared with alcoholic mortality, with attempted suicide, or with the several varieties of crime that are known to be most intimately connected with chronic alcoholism. The accompanying diagram, which I have published elsewhere, will epitomise this statistical evidence. It shows the rate per 100,000 of the population in the agricultural districts, the manufacturing towns, the seaports, and the mining districts of arrests for drunkenness, homicidal crime, and assaults taken together, homicidal crime alone, and attempts to commit suicide calculated on the annual average during the years 1891–1900. The figures below the columns are the comparative mortality figures for a number of the occupational groups which are more or less representative of the industrial conditions in each of the composite areas, viz. for the agricultural districts the agriculturists, for the manufacturing towns the textile and iron workers, for the seaports the dockers, and for the mining districts the coal-miners. The fact which I wish to bring out by means of this table is, of course, that drunkenness and chronic alcoholism are largely independent of one another, and that the more serious evils due to alcohol are connected with the chronic intoxication and not with simple drunkenness. This is most clearly seen in the mining districts, where there is more drunkenness than in any other part of the country, but where, at the same time, there is little chronic alcoholism and, therefore, relatively low rates of alcoholic suicide (as measured by suicidal attempts) and of alcoholic crime. And the explanation which I desire to suggest is, as I have already indicated, that the chronic intoxication is, in the main, a result of industrial drinking and has nothing to do with the convivial excess which produces drunkenness.

The difficulty of informing the relatives of patients suffering from dementia paralytica on the probable duration of the disease led the writer to inquire into those symptoms and signs which appeared to be of value in prognosis.

The following case presents certain points of interest. The extreme prominence of pain crises in the beginning is unusual. Suicidal tendencies in general paralysis are sufficiently uncommon to be noteworthy, though they are by no means as uncommon as is generally supposed. The same may be said of delusions of conjugal infidelity. Finally, multiple lipomata occurring in this disease have not, as far as I am aware, attracted the notice of any English author.

This fragmentary paper is to suggest rather than to inform. It is a bedside analysis of the urine in 969 female patients consecutively admitted into Claybury Asylum, and the notes cover a period of several years. Although the facts are many, the deductions are few, and although possibly nothing new is related, yet these notes involve an extensive collection of common details, and there has been some labour undertaken to present them. The summary may, I venture to hope, serve as an incentive to others to contribute more detailed statistics upon an aspect of mental diseases which is at present much talked of and much written about, viz., the relation of insanity to auto-intoxication and its dependence upon changed metabolism, particularly in an alteration through this changed metabolism of the normal functions of the kidneys, and I propose to run somewhat rapidly through the following headings. And first as to—

Gentlemen,—I need offer no apology for once more bringing this subject before you, as its importance demands our immediate and careful consideration. More especially is this the case at the present time, because since I last alluded to it (at our annual meeting in July, 1905) the Select Committee of the House upon the State Registration of Nurses, has given to our nurses the stamp of official recognition, by inserting in their report the following opinion:—“The claims for Registration of Mental or Asylum Nurses have been laid before your Committee. They are of opinion that a separate Register of Registered Asylum Nurses should be kept by the Central Body, to which should be admitted the names of Nurses who have served for not less than three years (in not more than two Asylums) and who have received the certificate of the Medico-Psychological Association and can produce satisfactory certificates of good character.”

Although the world will never again see anything like the great crusades of the middle ages, these events may be traced to causes which, though now of less force, still influence the human mind, appealing to the simplest and deepest cravings of our common nature.

While making observations upon the opsonic indices of the insane I noticed that the serum in many of the cases under observation when mixed with the red blood corpuscles of a healthy person agglutinated them.