In Sir William Gull's classical description of “A Cretinoid State,” which we now call Myxódema, in 1873 he thus describes the mental condition of his first patient: ∗—“In the patient whose condition I have given above there had been a distinct change in the mental state. The mind, which had previously been active and inquisitive, assumed a gentle, placid indifference corresponding to the muscular languor, but the intellect was unimpaired.” He noticed “changes in the temper,” and assumed that the mental changes were pathological and a part of the disease. In Dr. Ord's almost equally classical paper, in which he gave the disease its present name,† he referred to the “slowness of thought,” the “long and diffuse letters” of one of the patients. In every full description of any case of myxódema that I have seen some such morbid mental change has been referred to. In the Report for 1888 of the Committee of the Clinical Society of London on Myxódema, the mental condition of the patients was inquired into, but there is internal evidence that the reporters did not all understand mental symptoms in the same light. Slowness of mental action was the symptom most common, for its absence was only noted in three of the 109 cases. Delusions and hallucinations are stated to have been present in 15 cases, or 14 per cent., and actual insanity in 24 cases, or 22 per cent. There is very frequent mention of morbid suspicions under the mental heading, and memory is usually stated to be impaired where reported on. In his experiments on monkeys, detailed in the report, Horsley specially refers to mental symptons that followed extirpation of the thyroid. He says the “mental operations, normal at first, soon diminished in activity, and then follow apathy, lethargy, coma.” “Gradually the intellect became duller, the energy of the animal diminished, and apathy alternating with idiotic activity resulted.”

Dr. Clouston opened a discussion on this subject at one of the meetings of the Psychological Section of the British Medical Association at Newcastle, and I attended purposely to take part in the discussion and show the plans which I propose to describe in this paper.

Gentlemen,—My first and most pleasing duty in taking this chair is to thank you very warmly for the honour you have done me in placing me here. Recalling the names of those who have occupied this position before me, I am abashed by my sense of my own unworthiness to fill it. When the question of my nomination as President of this Association was mooted, I would fain have stood aside, but the kindly representations of those members who said that it was Ireland's turn for an Annual Meeting made me feel that I could not evade the honourable task which was put upon me, even though I feel that I am very far from being the fittest of my contemporaries to undertake it. I have also been moved to accept your kindness and the distinguished honour you have conferred upon me in the hope that a meeting might be arranged in Dublin in such a way as to further the objects of the Association and to be of advantage to the members, particularly to those who live in Ireland. How far this hope may be fulfilled remains to be seen. I trust, in any case, that our present meeting may be so far successful that all our future Annual Meetings may be working meetings, and that under successors, I hope more competent than myself, the Association may be thereby materially aided in its forward path. For this meeting we have, I am happy to say, a very large and comprehensive programme, the members having heartily seconded the efforts of the General Secretary and myself to bring in good material. I desire no credit for this. I may say, with Montaigne, “I have brought you here a nosegay of sweet flowers; nothing is mine but the string that ties them together.” It is, perhaps, the function of the Chairman of such a meeting as this rather to aid and to suggest discussion than himself to take a very prominent part therein; rather to offer opportunities for others than to make them for himself; rather to be the whetstone than the chisel—

It is only within the last two or three years that alienists have learnt to recognize the importance of the existence in cases of progressive paralysis of the insane of certain extremely interesting neuro-muscular anatomical alterations. Too long was the teaching of Lockhart Clarke,1 Tigges,2 Westphal,3 Magnan,4 Voisin,5 Mendel,6 etc., that the cerebrospinal changes represented the sole anatomical substratum of the clinical features in this disease, regarded as infallible, and it is pleasing to think that our erroneous conceptions have been removed by the energetic researches and discoveries of another generation, including among their number Déjerine,7 Lubimoff,8 Mierzejewski,9 Bianchi,10 Fürst-

When our worthy Secretary asked me to read a paper, my difficulty in giving a direct affirmative answer was not so much the trouble and time the writing of such a paper would involve, but rather the choice of a subject. To give the outlines of some special case, to make a few remarks, and to hear the President, after thanking me, and waiting in solemn silence for the spirit to move some member to start a discussion, call upon the reader of the next paper, did not strike me as worth the trouble; besides, one cannot always have a “special case” on tap in a small private asylum.

Ideas of persecution may be met with in nearly all forms of mental disease, but I intend at present to deal only with the cases in which these ideas predominate and constitute the very essence of the morbid condition.

I proceed at once to the analysis of the cases that have come under treatment in this asylum. The 730 cases under consideration comprise all the cases of melancholia admitted into the Cumberland and Westmorland Asylum during the twenty-seven years from the beginning of 1865 to the beginning of 1892.

I. Admissions.—The following table shows in decennial periods the numbers admitted at different ages, and the percentage proportion of admissions in each age-period:—

After reading the somewhat meagre discussion which followed the reading of Dr. Thomas Ireland's very interesting paper before the Section of Psychology at the 61st Annual Meeting of the British Medical Association,∗ it occurred to me that your readers might take some interest in a paper on the connection between hemp drugs and insanity in Bengal. The Hemp Drugs Commission is now sitting, and my paper will consist mainly of the evidence already given to me, in the shape of a report, to that Committee. To avoid unnecessary prolixity, I will first of all refer your readers to an excellent report by Surgeon-Captain David Prain, I.M.S.,† which was published a short time ago by the Bengal Government. This report deals fully with the botanical and economic side of the question, and gives also a good resumé of the chemistry of cannabis sativa.

A modern philosopher has revived the theory that music has been evolved out of speech; but even adopting the leading views of the evolutionists, this theory seems little in accordance with their own methods. The harmony of sound appears very low in the animated kingdom, whereas the faculty of speech is the last and highest endowment. Some insects and spiders have the power of producing sounds. This is generally effected by the aid of beautifully-constructed stridulating organs. “The sounds thus produced,” Darwin tells us, “consist in all cases of the same note repeated rhythmically, and this is sometimes pleasing even to the ear of man. Their chief, and in some cases exclusive use, appears to be either to call or to charm the opposite sex.”

The question of the increase of insanity in Ireland is, of course, but a part of the much larger question, the increase of insanity generally, all the world over. But there is one peculiarity about Ireland which has been repeatedly noticed, of which, as yet, no adequate explanation has been forthcoming, namely, that while in other countries insanity has increased along with, and in a higher ratio than an increasing population, Ireland alone of all civilized countries, so far as I am aware, possesses the unique and unenviable distinction of a continuously increasing amount of insanity with a continuously decreasing population; and, what would appear to be an almost necessary consequence, the proportional rate of increase in Ireland is far beyond what exists elsewhere. The aim of this discussion then, it seems to me, should be directed not so much towards explaining such increase in insanity as Ireland shares in common with other countries, as to an endeavour, if possible, to account for the preponderance, or the assumed preponderance, of insanity in Ireland over that of other countries.

It was my fortune to spend a week at Göttingen in the month of May of this year, and the following notes of conversations and extracts from the published writings of Professor Meyer† may be taken as representing the opinion of the best German school of psychiatry at the present time. Professor Meyer's career has been long and distinguished. Educated at Berlin, imbued with an enthusiasm that impelled him to teaching there as early as 1858, he was in due course appointed to the Hamburg Asylum, whence he was transferred to Göttingen more than a quarter of a century ago. His name is familiar as an authority on mental diseases, and his present position is indicated by his having been selected to report upon “Psychiatry,” in the volume descriptive of the German Universities prepared for the Chicago Exhibition.

I read, at the time of its publication in 1886, and again in 1890, after a visit to Dr. Tuke in London, his first paper on the “Alleged increase of insanity,” and I await with much expectation the full text of his recent paper on the same topic. The conclusion that I draw from the statistics there presented (in 1886) is not exactly the same that my friend Dr. Tuke draws. I distrust very much the records of first attacks; so far as my observation goes—extended now over a period of 30 years, and many thousand cases of insanity whose certificates I have separately examined—there is nothing in the proverbially doubtful statistics of the insane more dubious than those affecting to give the date of a “first attack.” Even for purposes of comparison, year by year, they have scarcely more value than a mixture of pounds sterling, years of our Lord, bushels of wheat, and a few other numbers jumbled together in an account, so totally varying are the judgments and the exactness of the certifiers who set down the alleged “first attack.” Until these variances can in some way be reduced by the better observation of the asylum physician, I, for one, am inclined to leave the tabulation of “first attacks” where good sense has long left the asylum tables of “causes of insanity.” One may possibly be as good as the other, but neither can throw any clear light on the real facts of insanity.

The subject of Music and the Musical Faculty in connection with insanity is one which has several interesting aspects, and one which, in some directions, offers for observation a field which has hitherto been little worked. I propose to bring together in this paper some of the facts which have fallen under my notice, and to offer a few comments upon them.

I have endeavoured to prepare tables on Irish Lunacy corresponding to those which I have given in my paper∗ on the “Alleged Increase of Insanity in England and Wales.”

It is now several years since I first proposed the operation of trephining the skull in general paralysis of the insane, at about the same time that Dr. Batty Tuke independently operated for the same disease. Others have also performed similar operations, but the results have not been publicly recorded or collected. Sufficient time has not elapsed, nor have the cases been sufficiently numerous to determine the future of the operation, whether it is of sufficient service to justify its frequent employment or whether it must be dismissed to the limbo of useless remedies. I have published cases where considerable temporary improvement has resulted, where life has been prolonged, and distressing symptoms alleviated, and I propose to give to the Association the short details of a hitherto unpublished case where no candid critic could, I think, deny the improvement that I claim for him. This much may be said for the operation—that it seems harmless when carefully performed, no fatal result having, as far as I am aware, ever resulted. The apprehended after-results, as regards local tenderness, liability to injury at the trephined spot, bulging of the contents of the cranium, are phantoms which have no basis of fact. I fear, indeed, that we have not been bold enough in our measures. Mr. Harrison Cripps, who performed the earlier operations for me, recommends the removal of a much greater extent of bone, of a piece indeed about three inches square, and he would do it on both sides of the skull. Of the after results of removing so large a piece of bone I should have no more fear than I have of the present comparatively small area; the great objection I have to the removal of so much bone is the long time required for the operation. Another point is with reference to the time chosen for the operation. I think it should be done earlier, it seems hopeless to do it in the later stages, after there is much thickening of the membranes and destruction of tissue—as far, at least, as any hope of cure is expected, anything, indeed, beyond relief.

I propose in the following article to state succinctly, and I trust fairly, the arguments and facts on the affirmative and negative sides of this question, confining myself to England and Wales, and endeavouring to determine on which side the greater weight of evidence lies.

Probably most medical officers of asylums have experienced during the last few years an increasing difficulty in obtaining reliable nurses.