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—

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.

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.

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.

The term cerebral pressure requires more exact definition, and ought, I think, to be entirely superseded by a more generic, comprehensive, and intelligible name. It should not be taken in the limited sense of only including fluid pressure, but should be extended so as to embrace a large variety of clinical and pathological conditions.

The patient was admitted into Mavisbank Asylum on the 5th of October, 1891, suffering from monomania of suspicion of probably about a year's duration. He was a well-nourished man, 50 years of age, 66 inches in height, weighing 1601bs.

Every physician in charge of a hospital for the insane should do all in his power to aid in the advance of mental physiology, mental pathology, and physiological psychology, not only for his own immediate benefit as a study; but with the intent of reaching a better knowledge of the mental processes, and elucidating, as far as possible, the recondite problems of mind. These require careful and exact study, but that study will give power to the individual, while it will enable him more definitely to trace the intricate connection of cause and effect in the cases which call for his examination. It is certain that the more thoroughly these processes are studied the better will be the effect of treatment, and the more satisfactory will be the result to the patient and to the physician. He will learn more fully that while medical study than it has yet received; and by the knowledge thus obtained a way will be found for the more scientific application of medical, moral, and hygienic measures than they have heretofore received.

It is an undoubted fact that the diagnostic terms moral insanity and obsessions have been the cause of serious misconceptions in science and in criminal practice; and, further, that such misconceptions may paralyze justice and menace the moral standard and even the safety of society. It nevertheless marks a great advance in the progress of psychology to have recognized that many criminal and vicious acts result from congenital defects. These defects are sometimes accompanied by atypical anatomical forms of the body, and especially of the skull; but the value of these abnormalities is relative, not absolute.

The subject which I have the honour to bring before this learned Association concerns persons whose mental condition is unsatisfactory, either by arrest of brain development before birth or in early childhood, or as a result of altered intelligence following injury or acute disease in infancy, in adolescence, or even in adult life.

Up to the end of the sixteenth century the body of the suicide was treated with barbarous cruelty. This was the outcome of the canon law rather than the civil law, and the Church still clings to a belief in the efficacy of old-time procedure. Only the other day (February, 1894) the Archbishop of Canterbury said that “the increase of suicide is largely due to the now almost universal verdict of temporary insanity given at coroners' inquests;” and he further referred to the burial of suicides in consecrated ground with former practices. The sole disability under which a suicide now lies is that which he suffers at the hands of the Church, and it is to enable him to escape that that coroners' juries deliberately perjure themselves by finding verdicts of temporary insanity where there is not a tittle of evidence to support such verdicts.

Many of those now present will probably agree with me that the law of criminal responsibility, as at present laid prisoners is not the same in England, Ireland, and Scotland. The existing law is ruled by the answers of the judges to certain questions put to them by the House of Lords in reference to the case of the “Queen v. McNaghten,” tried in 1843.

Some time since, when moved to speak on behalf of the insane population of Irish Workhouses, I did not fully contemplate the many difficulties of the task before me; and now, when we are on the eve of promised legislative measures, it may seem unnecessary to enlarge on this subject, as it is to be presumed that the philanthropy which has urged the Executive to take up the cause of pauper lunatics in our Workhouses, has formulated a Bill embracing all that the heads of the Lunacy and Poor-Law Departments can suggest. Nevertheless, it may not be without effect to elicit from those present to-day, representing as they do the special knowledge of insanity in this kingdom—I may indeed say in Europe—some expressions of opinion on a subject which in one shape or another must have been presented to their observation in the course of their experience. In asking your attention I feel that the subject commands your sympathetic interest, as, of all others, you can fully realize the extent and malignity of the disease, and the urgency for suitable remedies.

My attention has been drawn to the question of fresh Lunacy Legislation for Ireland, by the report of a Committee which was appointed by the Lord Lieutenant of Ireland in 1891 to enquire into the lunacy administration of this country.∗

I desire to call attention to a mode of treatment which has not yet been generally adopted in cases of goitre, and to submit two cases in which thyroid gland was administered. The preparation used was five grains of the extract in tabloid form. The result in both cases was highly encouraging, though one was much more so than the other from a mental point of view.

About the close of 1892 I examined bacteriologically some cases of othæmatoma, with a view of ascertaining if there was any basis for the idea which occurred to me, and which I mooted in an article in the “Journal of Mental Science” for April, 1893, that that condition was the result of bacterial activity. In none of the cases examined was there a history of injury. In the first two (an adult imbecile and a chronic maniac) cover-slip preparations of the extravasated blood—taken with full precautions as regards cleanliness—showed staphylococci, singly, in twos, in fours, and in small groups. In size the cocci resembled closely S. pyogenes aureus or albus. An attempt to cultivate the organism on gelatine and broth failed; unfortunately no agar was at hand. In the light of subsequent experience, I believe that this failure may, with much probability, be attributed to the fact that the amount of material transferred to the culture-tubes was too small. Several drops of the sero-sanguinolent extravasate should be taken for each tube. In the third case (that of a dement) what appeared to be the same organism was found in the cover-slip preparations and grown upon broth and altogether like that of a cultivation of S. pyogenes aureus. In other tubes, however, the growth remained white throughout, so that S. pyogenes albus was present as well.

Of recent years a considerable amount of study has been devoted to the nerve changes which are to be found in sane patients dying during the senile epoch, but comparatively little has been written concerning the alterations which occur in the nervous system of aged insane individuals. The object of this communication is to attempt from the pathologist's standpoint to elucidate some of these characteristic senile phenomena. I propose to briefly describe the morbid changes, both macroscopical and microscopical, which in my experience occur in aged insane persons, and to conclude by offering some remarks on the pathology of certain of these phenomena which I have particularly investigated. Before proceeding further, I would mention that the entire material for my observations has been afforded by the Lancashire County Asylum, Rainhill, and to Dr. Wiglesworth, the Medical Superintendent of that institution, I am indebted for permission to make use of that material and the asylum records in the compilation of this paper. My investigations have extended over a period of 18 months, and comprise the partial examination of the nervous system of all patients over 60 years of age who have died since my appointment as pathologist to the asylum. Of such cases θere have been 22 males and females their average age bone a matter of difficulty. In cases where no adhesion exists and the calvarium is readily removed, a slackness and dimpling of the dura mater—particularly of the frontal area—is generally seen, and proclaims an atrophy of the enclosed parts. The subdural hæmatoma or so-called pachymeningitis interna hæmorrhagica, so frequently met with in general paralysis of the insane, is not uncommon in senile insanity. Of 54 cases of that affection observed by Dr. Wiglesworth1 in this asylum, 12 occurred in patients over 60 years of age, while in a series of subdural hæmatomata collected by Sir J. Crichton-Browne and Dr. Bevan Lewis2 at the Wakefield Asylum, nine per cent, occurred in cases of “pure senile atrophy” of the brain, and 26·5 per cent. in cases of “chronic disorganization of the brain” (which, I take it, includes many senile cases); and, lastly, of the 50 cases of senility which I have examined, four presented this condition. The subdural fluid is invariably increased in quantity. The arachnoid membrane, particularly that covering the sulci and meningeal veins, is generally opaque, and the pacchionian bodies hypertrophied. A subarachnoid hæmorrhage I have only seen in one case, viz., in a demented female, æt. 78, who a few days before death suddenly became partially paralyzed in the extremities of the right side. At the autopsy an extremely wasted brain with a great excess of cerebro-spinal fluid was found, and lying in a hugely dilated subarachnoid space, situated at the point of junction of the horizontal limb of the intra-parietal sulcus with the post-central sulcus on the surface of the left hemisphere, was about 1½ ounces of dark, clotted blood and sanious serum. This was obviously pressing upon subjacent parts of the ascending parietal, superior parietal, and supramarginal convolutions—hence the paresis. The source of the hæmorrhage was not discovered, but that it issued from a ruptured, small pial vessel was doubtless. Further, that the hæmorrhage had actually occurred into the subarachnoid space was undeniable, as the stretched arachnoid membrane was clearly distinguishable confining it, and on the surface of the underlying cortex, which, by the way, was not lacerated, the delicate pia mater could be plainly traced. in fact, can often be detached in one sheet, but it does happen in some cases, especially if the brain be somewhat decomposed, that its removal is accompanied by a decortication exactly similar to that which is described as characteristic of general paralysis. In all the senile brains which I have examined there has been more or less atrophy and decrease in weight, and in some cases it has reached an extreme degree, leaving thin convolutions, and wide, shallow, gaping sulci. The frontal segment invariably suffers most, and the cerebellum and the mesencephalon participate in the wasting. The following table shows the average weight of the various parts of the brain in the cases I have examined:—

A. Clinical, by Dr. Conolly Norman.

N. P. was admitted to the Dublin District Asylum in February, 1886. Nothing was known of his antecedents, nor was there any history whatever save that he had been guilty of an unnatural offence, had been committed to prison, and had been found to be insane. He would or could give no information about himself.

Dr. Clouston explained that he was the spokesman of Drs. Middlemass and Robertson, who had made almost all the sections and had supervised the micro-photography. He explained that as yet micro-photography had many disadvantages owing to the very delicate structure of the brain and the high powers that had to be used, as well as the difficulty in photographing many of the aniline stains. In the case of some of the sections more than six slides had been made before a satisfactory photograph was got.

It is not suggested that the specimens to be shown on the screen afford anything like an exhaustive demonstration of the constituents of a convolution. They are mainly intended to show the extreme value of Golgi's method for elucidating the important anatomical connections between cell and cell, and between area with area. Dr. Clouston must be congratulated on being able to submit such an admirable series of slides illustrative of the microscopic morbid anatomy of the brain. One experiences a feeling of envy of the rising generation at being able to start so far along the road. When I some thirty years ago began such investigations I could not make a section—only two men in Great Britain knew how to do so. I had to commence at zero; and I shall never forget the feeling of satisfaction when for the first time I was able to demonstrate a nerve-cell by my own unaided efforts. But methods of imbedding, cutting, and staining were soon discovered, and those of us who were working at the subject were, within a few years, able to demonstrate, describe, and figure a large proportion of the morbid changes which have been so brilliantly exhibited to-day. With such a demonstration the first volume of the pathological anatomy of the insane brain may be considered to be closed; it may have to be re-opened from time to time for marginal notes, but for all practical purposes of the post-mortem theatre we know roughly the general characters of the changes in the membranes, vessels, cells, and glia, so far as they can be made out by the Bevan Lewis and other methods. The second volume must deal with interruption of connections due to changes in the cells. This will be a long and difficult task; but if, as we have seen to-day, so much has been overcome within the last thirty years, we may fairly anticipate that the next generation of workers will accomplish very much more. The great value of Golgi's method and its modifications is that the various processes of the cells can be traced for long distances, and the characters of their insulating material can be demonstrated. When I place before you the best demonstration of a nerve-cell that can be obtained by aniline staining and another prepared by Golgi's process, you will at once see the immense advance that has been made. In this section of a great pyramid the character of the axis cylinder process at the base is seen to differ from the “splendid tufts” (as Ramon y Cajal calls them) in which the apical protoplasmic process ends; the basal axis cylinder is shown to bifurcate and to throw off numerous collaterals; and the lateral protoplasmic processes can be traced for long distances. The apical processes and the “splendid tufts” present a mossy appearance, differing in this respect from the apical poles of cells of other zones, and from the basal axis cylinder process of the pyramids. It can be determined that these processes are never anatomically connected; therefore, that the impulses they convey must be transmitted by contact only. When discussing lately with Prof. Cuningham the probable function of this mossiness I suggested it must be for the purpose of presenting a more extensive area of contact, and this view is supported by the interesting statement made by Dr. Andriezen that he has found in chronic dements that the mossiness has been lost or much diminished. Ramon y Cajal has, by his modification of Golgi's process, demonstrated the important fact that the poles of the external or molecular layer, of the pyramidal zone, and of the internal or polymorphous layer differ in their distribution, those of the outer zone being directed horizontally, and for the most part antero-posteriorly, and never descending; that the axis-cylinder process of the pyramid is in direct communication with the projection fibre, and probably with the commissural fibre; that its apical process runs up to the surface of the brain; and that the poles of the great cells of the polymorphous layer never extend beyond the pyramidal zone. This, along with the demonstration of the large cells (Cajalsche Zellen) of the molecular layer strongly suggest that each zone exercises special functions. It is impossible on the present occasion to go into further particulars. I must apologise for the roughness of the demonstration. I thought it might interest some members to be able to see what important results may be looked for from the use of Golgi's and Ramon y Cajal's methods. If we hold that mental action is a function of connection it is of extreme value to have at our command a method of investigation by which may be shown that the cell-processes suffer a Wallerian degeneration as a consequence of the implication of cell integrity.