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NOVEMBER 4, 1922.

Bradshaw LectureON

MENTAL SYMPTOMS IN PHYSICALDISEASE.

Delivered before the Royal College of Physiciansof London on Nov. 2nd

BY SIR MAURICE CRAIG, C.B.E., M.D. CAMB.,F.R.C.P. LOND.,

PHYSICIAN FOR PSYCHOLOGICAL MEDICINE, GUY’SHOSPITAL, LONDON.

WE are met to-day to honour the memory of Dr.William Wood Bradshaw. He was born at Bristol in180J and was educated at Westminster and MiddlesexHospitals. At the age of 43 lie matriculated atNewton Hall, Oxford, and was granted a degree withoutany examination. He never did much practice, but itis on record that he was generous and charitable inhis treatment of the poor. Sir James Paget states that" he was a home-loving and studious man who dili-gently cultivated his mind in both literature and art."His ’wife, although many years older than himself,outlived him by several years, and it was a bequest inher will which endowed this lecture in memory of herhusband. I have to thank the late President of thisCollege for the honour he has done me in nominatingme to deliver the Bradshaw Lecture this year. I feltgreat diffidence in accepting this important position,and the doubts that I had 12 months ago as to mycapacity to fulfil this duty have increased ratherthan lessened. The subject which I have chosenfor this thesis is " Mental Symptoms in PhysicalDisease." "

The close relationship of mind and body has longbeen recognised, but in practice this inter-relationshiphas been largely lost sight of and the tendency hasbeen to investigate them apart to the detriment ofour knowledge of each. It shows how dominated weare by tradition when we realise that it is customaryfor a student to pass through his medical instructionin the wards of a hospital with little or no thoughtgiven to the mental aspect of the patients he has beenobserving. It is true that he will hear something ofhysterical manifestations, but I venture to think thatthis narrowed purview of mind-standing alone, aswe so often find it-is misleading, for it is apt toconvey to the student that hysteria is the beginningand end of functional nerve disturbance. It is en-couraging to learn that the term " mental " is nowgenerally used when reference is being made to normalmind. For this has a dual value : it brings the studyof normal and abnormal mental states into closerrelationship, and it emphasises the fact that the mentaloutlook of both the healthy and the ill man shouldbe investigated. It must be conceded that all physicaldisease has a concomitant mental change just as allmind disorder is associated with variations in thebodily functions. It is true in the former themental change in some cases may be so slight asto be patent only to the close observer, butthis indicates that adaptation must have beenadequate. If adaptation is incomplete or fails, themental change will be correspondingly greater. Con-sequently it is the neuropath who in the first placewill show nervous symptoms, as his resistances areweaker and his powers of adaptation may be small.On the other hand, if a stimulus is severe, even thoseendowed with a normal sensibility must suffer. Thata symptom is unobtrusive and does not attractattention does not connote that it is unimportant ;indeed, the more closely we study medical science,the more often do we find the converse to be true. Atiymptom which quickly attracts attention may be ofsmall moment, were it not that it frequently maskssomething which is all-important and which can onlybe disclosed by a more thorough examination. Neither I

should mental disturbance arising in physical disease,when discqvered, be treated lightly, as not infrequentlyit may be the deciding factor in the ultimate fate ofthe patient.The close inter-relationship of all the various

systems of the body is increasingly emphasised byphysiologists, pathologists, and clinicians, and recentwork upon the vegetative nervous system calls forfurther careful investigation. We are told, forexample, by some that the thyroid gland is one of thedefensive mechanisms of the body, and that anycondition which gives rise to the sympathetic stimula-tion of this gland may by setting up other changes giverise to other nervous symptoms, which, again reactingupon the gland, tend to establish a vicious circle. Insaying this it is necessary to add the caveat put forwardby Prof. Swale Vincent in the Arris and Gale lecturedelivered this year before the Royal College of Surgeonsof England. He states that " in the minds of manyphysiologists there is a growing suspicion that thechemical regulation of the bodily functions is not of thesupreme importance that certain schools would haveus believe." The pure clinician is apt to seize uponan explanation which seems to fit in with anysyndrome of symptoms with which he is confronted,and the physiologist working in his laboratory isapt to overlook a clinical picture which he neverhas the opportunity of seeing. Fortunately thisis all changing and in the future we shall see

clinical physicians and pure scientists working inmuch closer relationship.

H YPERaeSTHESIA AND PAIN.

It is important to try to discover some fundamentalprinciples as to how and why mental symptomsdevelop in association with physical disease, for byso doing the task in front of us will be simplified. Inthat sensation is the most elementary of all consciousprocesses and that it is largely upon sensation that -weform a knowledge of self, alteration in sensation, fromwhatever cause, must clearly give rise to mentalsymptoms. Sudden and extensive variation insensation will give rise to more marked mentalchanges, but any subacute and persistent alterationwill be definitely reflected in the mental outlook ofthe individual. For example, physical changes leadingto a hyperaesthesia of the abdominal area often giverise to what is commonly spoken of as hypochondriasisand the danger is that from this time onwards thegeneral physician is apt to regard the patient as

having passed outside his province, whereas thedisorder is the same except that it has extended itseffect to other systems of the body. Every organ,and indeed every structure of the body, must berepresented in the field of consciousness, but thestimuli arising from them only arouse consciousness oftheir existence when they are raised above a normalintensity. On the other hand, it is possible to obtaina relative hypersesthesia by the lowering of sensitivityin the surrounding tissues.Pain is one of the most common changes in sensation

and because it is so common one is apt to fail toappreciate the influence it may exert upon an

individual. From the philosophic standpoint painhas been regarded as something of value to theorganism and as tending to favour its survival. Butpain is not always related, either by its cause or byits persistency, with some definite abnormality ofwhich it is a more or less precise indication of constantvalue. There is one dominant characteristic of painand that is its tendency to persist long after theoriginal cause has ceased to operate, and the longerit exists the more difficult it is to relieve. Theimportance of the matter may not end here, for inthe great majority of persons pain is associated withdefinite mental changes, such as irritability and rest-lessness, neither of which can be regarded as benignsymptoms. Further, sleep is interfered with and inconsequence more severe disturbances of the emotio nmay result. Pain evokes the same physical changesthat are aroused by emotion, and they appear in orderto brace the organism to face and overcome the

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situation that confronts it. Now the energy thatmust be dissipated by the mobilising of these forcesmust sooner or later lead to exhaustion, which, in part,is observable by changes in the mental processes. Insome persons the exhaustion is much more noticeableon the physical side, whereas in others the fatiguedstate is more observable in changes in the mentalattitude. Certain investigations suggest that theendocrine glands once over-stimulated may remain ina state of over-activity for a long time and in con-sequence keep up a hypersensitive condition of thenervous system; if this is so, it is a matter of nosmall importance.

EMOTION AND PHYSICAL HEALTH.

Apart from severe pain there is no symptom socapable of initiating bad mental habits as discomfort.Tics are all good examples of this, but some of themlead to permanent ill-health, unless understood andsuitably relieved ; aerophagy is an instance of this.During the last decade, and more especially owing tothe work of Déjerine, emotion has come to be regardedas one of the most important factors in the mentaland physical health of an individual. It may arise Ifrom an external or an internal cause. By its sudden-ness or by its intensity emotion may completelyoverthrow the equilibrium of the subject whoexperiences it. As Déjerine writes, " Under the influ-ence of an emotion a man will become incapable ofany conscious action or judgment and deprived ofhis most elementary perceptions ; feeling nothing,seeing nothing, and hearing nothing, the subject istransformed into a simple automaton." This con-dition may on rare occasions be lasting ; it is more ecommon to have a gradual return to normal self, butthis return is by no means even and is often inter-rupted by a series of relapses. What I have justdescribed must be regarded as a maximum emotionand there are gradations from the very smallestdisturbance to this violent reaction. Even a lesseremotion if it lasts may set up a very definite "pre-occupation," which in turn may lead to some mentalchange. Every person has his own way of reactingto emotional excitation, and in some instances anexternal emotional stimulus, such as the shock ofhearing bad news, only develops its full potency afterbeing reinforced by internal emotion-for example,when a patient has been told some disquieting newsregarding his health, or when he may have inferredfrom some gesture or expression of his medicaladviser that his condition is serious. We may beunable to adapt to an emotion once it has arisen, andit can best be prevented or held in check by anintellectual understanding of its effect. Emotionarising from whatever cause quickly affects theappetite and digestion, and if it persists there is asteady deterioration in the body-weight and in thegeneral health of the patient, and yet it is common tosee these conditions being treated as if the error in the

Idigestion were the primary cause, and indeed, the Iphysician too often remains in entire ignorance of thefact that some disturbance of emotion is the real causeof the mischief. Therefore it is clearly importantfor every physician to have some insight intothe mental make-up of his patient. Mostauthorities now agree that the potential neuras-

thenic has what may be spoken of as an

emotional constitution and that even a slightemotion which persists for a long time may bringabout the condition. Nevertheless, whether theemotion is severe or slight, if it occasions loss ofintellectual control, it tends to the establishing of aneurasthenic state, which in turn leads to a lesseningof the power of adaptation in the person so affected.In some cases the neurasthenic condition may becomplex, but in others it may be limited to thedisorder of function of some organ of the body. To thistype belong those individuals who develop fearsregarding their heart, their lungs, or indeed any organof the body ; the condition may persist long after theoriginal emotional cause has disappeared and the

patient has regained full intellectual control.

SUGGESTIBILITY IN HYPERSENSITIVE PERSONS.

The ill person is very suggestible, especially towardsa morbid outlook, and any remark made by a physicianmay be so exaggerated and distorted as to lead to apre-occupation of an important kind. I recall duringthe recent influenza epidemic the case of a woman, ofa nervous type, whose illness was marked during itsacute phase by profuse perspiration. She was warnedto be careful not to expose the skin unduly when anysweating took place, and in consequence she kept thebed-clothes drawn closely up to her chin and foodwas administered by the nurse. The drenchingperspiration continued for several weeks in spite of anormal temperature, and when I saw her eight weeksfrom the beginning of her illness she was becomingdepressed and sleepless, with a fear in her mind thatthe perspiration indicated the presence of some moreserious condition than she had yet been made aware of.In spite of the profuse sweating she had gained in body-weight, and the pulse-rate and heart condition weresatisfactory. Further, it was observable that a suddennoise might occasion a free perspiration. Everythingpointed to the condition being a secondary mentalone, and so it proved to be, for during the weekfollowing a full explanation to her of the mental causeof the sweating, and being reassured that there wereno risks attached to exposure even if she were dampand feeling cold, she only had one perspiration, andcontinued to make a steady and rapid recovery. Thedanger in this type of case is the establishment of ahabit ; I need hardly say that the longer the habitlasts, the more difficult it becomes to correct it. Itis useless merely to tell a patient that this or thatsymptom is unimportant, especially if at one timeit has been otherwise regarded ; the medical advisermust go fully into the matter with his patient untilthe latter has a satisfactory understanding of hisstate.Take another type of case-the patient whose illness

necessitates an operation. The number of persons whobreak down either immediately after an operation orsome weeks later is larger than some may suppose,and many of these breakdowns can be traced back tothe emotional shock that the individual receivedwhen he was told that an operation was necessary.If this is true-and there is plenty of evidenceto support it-it strengthens the claim thatit is essential to understand the mental sideof the ordinary patient. As I have alreadystated, emotional shock leads to pre-occupation.and pre-occupation leads to sleeplessness withits resultant nervous and mental fatigue. Highlyhypersensitive persons should not be told of the needof an operation long before this is to be performed,and after any discussion of this nature the patient’ssleep should be carefully watched and sedativesadministered if necessary. Also, with this class ofcase violent purging a few hours before the operationshould be avoided if possible, as this increases thedanger of a nervous collapse with mental confusionafter the operation. The work of Crile and Lower onsurgical shock is highly suggestive and claims theattention of physicians as much as that of surgeons; Ithey conclude that shock is a state of exhaustionwhich leads to changes in the brain cells, the liver,and the adrenals, and that the shock can be broughtabout in many ways. They recognise that there isno distinction between emotional shock and shockproduced by other means ; the clinical phenomenaare practically the same, and they state that thecellular changes are apparently identical, and theirobservations lead them to conclude that the conditionis brought about by an intracellular acidosis. If theyare correct, disturbances of the emotions such as fearand anxiety must take a prominent place in themedicine of the future. It is noteworthy that duringrecent years-no matter in what direction investiga-tions may have taken place, whether from the physio-logical side or the pathological study of certainphysical disease, or from the purely psychologicalstandpoint-emotion has revealed itself to be a factorof importance. Although childbirth cannot properly

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be included in a thesis on physical disease, I shouldlike here to mention a point which does not receivethe consideration that it deserves. Many women,especially those in ill-health or from some cause in afatigued state, whether this is from the disturbed

sleep so common in the later months of pregnancy orwhether from some stress, are in a highly unstablestate by the time that labour begins. The emotionwhich is always present in a greater or less degreeat this stage may pass the normal limits, either fromdread of the ordeal which confronts the patient or fromthe actual suffering at the time the baby is born.Such women should be protected against thisstrain by taking care that the hours of sufferingand the intensity of it are limited ; yet toooften we find that these precautions or ignored,largely on the false argument that the process is apurely physiological one. An emotional disturbanceof this kind may lead to years of ill-health, even ifthe patient escapes a severe mental breakdown atthe moment. Emotion once aroused may not settledown and nearly always leaves the person moresusceptible to other emotional shocks.When we appreciate that few persons are free

from anxiety, financial or otherwise, at the timewhen illness overtakes them, and that added tothis the patient may be fearful as to the resultof his disease, it is obvious that mental changes

must take place. Experimental research has shownthat fear may so exhaust the organism that deathmay supervene. Both physicians and surgeons knowfrom clinical observation how devastating is fear, andhow some patients who face an operation or an illnessunder’ this influence die without there being anyapparent reason for a fatal termination. To removesuch fear if it is possible-and often it is possible-isas urgent as it would be to control persistent vomiting ;yet in practice it is common to see the panic acceptedby the medical attendant in a fatalistic way withnothing more than a regret that his patient is so

foolishly nervous. The fearful person can usually bereassured, but he who would undertake to do thiswill best succeed if he has some knowledge of mindand its working. On the other hand, largely owing toignorance on these matters and under the falsebelief that they are bracing up their patient, somemedical men do infinite harm by their remarks,especially if these include words of reproof. It is truethat one fear may for the moment replace anotherfear, but I need hardly say that this is highlyunscientific and is no more a remedy than is a lavishexpenditure of sympathy. As the lay public largelytake their cue from the medical man, any words ofreproach he may have thought fit to deliver will inmany instances be added to by the nurse and someof the friends. Fear and anxiety, as I have alreadynoted, bring about a condition of mono-ideation inwhich the patient is unable to turn his attention awayfrom the morbid thought which seems to fill his wholemind. As he rationalises, he becomes more and moresatisfied with his own interpretations. He mayrepress them, for, at any rate in the earlier phases ofhis illness, he may recognise that they do not accordwith the opinions of others, but on the other hand hewould gladly disclose them to anyone capable ofappreciating his point of view.

THE IMPORTANCE OF SLEEP.If the pre-occupation continues it will begin to

interfere with sleep, which becomes defective both inquality and quantity. Insomnia aggravates the con-dition and in some persons quickly brings aboutserious mental changes. Crile found that sleep was theonly certain means of restoring the exhausted cells inthe brain or liver and adrenals. Animals becomeexhausted and die if kept awake continuously for sevenor eight days, and yet it is not uncommon to findsleeplessness in a sick person being treated in a half-hearted way. As a; profession we have become undulyapprehensive of giving hypnotics. ’ Experience hastaught me how dangerous is this outlook, for insuffi-cient sleep-especially under certain conditions-is

infinitely more damaging than any drug ; as for thedanger of inducing a habit by giving a hypnotic, ifwe omit the morphia and opium group, which shouldnot be given, the risk is infinitesimally small. On theother hand, I believe that the physician who putsoff prescribing a hypnotic as long as possible is theman who may bring about the habit he so much dreads,for he has by his methods permitted the patient tobecome obsessed by fear that he will not sleep, andwhen at last a drug is given and sleep is obtained, thepatient is terrified of the experience he has passedthrough and of ever again having a sleepless night.Insomnia that is quickly relieved leaves no suchmemories, neither does it make the patient rely uponany artificial aid. I refer to this matter, as sleepless-ness, like mental changes, has largely been neglectedwhen treating physical disease, and yet insufficiencyof sleep may give rise to disturbances of function inalmost every system of the body, and these disturb-ances may complicate disease and retard recovery,even if the patient escapes more serious consequences.

HALLUCINATIONS IN THE PATIENT.

It is outside the scope of this lecture to discusswhether a psycho-neurosis may develop into a

psychosis ; my experience strongly favours the viewthat this may take place, but for the moment thepoint is that any mental symptoms arising in associa-tion with physical disease should receive the con-sideration that their presence merits. As in othermatters of life, the proposition is divided into twoportions : the facts, or as it is in medicine, the definitesymptoms, and the inference or deductions that wemake regarding those facts or symptoms. Now thebody in health occasions few if any conscious sensa-tions, and in consequence when they do arise thepatient is apt to place his own interpretation uponthem, and unfortunately the explanation is too oftenwrong. Altered sensation may be so severe as to,occasion a patient to construct a definite delusionregarding it, but it is more common for him to havesome fear as a result. This in turn may set up anemotive state, and this psychic reinforcement, whenit occurs, greatly enhances the importance and theseverity of the condition. As already stated, thedisturbances of sensation may be local or diffuse,and they may be nothing more than some definitealteration in sensibility or may give rise to actualpain. Head’s notable work on the mental changesthat accompany visceral disease has not yet receivedthe attention which it deserves and which must someday be accorded to it, and it should be re-read in thelight of more recent psychological work. He pointedout the varied moods that may arise in conjunctionwith pain of the reflected visceral type and thesuperficial tenderness which accompanies it. Hestates that " although reflected visceral pain seemsto be the one universal concomitant of these mentalchanges in cases of visceral disease amongst sanepersons, other factors predispose to their appearance,"but in the cases upon which he based his investigations.he rigidly excluded all those in which there was a.

heredity of insanity or epilepsy. In addition toaltered moods, Head found that under certain con-ditions some persons suffering from visceral diseaseare liable to develop hallucinations of sight, of hearing,and of smell. He further found in those personswho had visual hallucinations that superficial tender-ness of the visceral reflected type was present over theforehead in every one of the cases, whereas in thosewho exhibited auditory hallucinations the’tendernesswas present in the vertical and parietal regions.The importance of the condition is not so much thesensory disturbance as the emotion that such a pheno-menon may set up in the patient. It does not requirea great imagination to appreciate what a disturbingeffect these sudden hallucinations may have uponhighly sensitive persons, and it is no cause for surprise-that many of them draw the inference that theirminds may be going. As they are sane persons,their fear may be quickly allayed when the truenature of the disturbance is explained to them, but

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the tragedy of the situation is that, owing to theneglect of a systematic investigation of the mentalaspect of a case by the general physician, the latteris often not conversant with the phenomena we aredescribing, and either he is unable to reassure hispatient or-what is worse-he conveys to him thedoubts that he has in his own mind. Many of thesehallucinations are hypnagogic, and occur when thepatient is in a half-asleep and half-awake state. Onthe auditory side the sensory disturbances may takethe form of tapping, knocking, bells, musical notes,the name called, and even at times a few words.When they first occur the patient is startled,and this gives rise to palpitation and a feeling of

apprehension.Head states that when visual hallucinations arise

in visceral disease, in all the cases he observed theobject appeared white, black, or grey-never colouredor even tinted. He found that almost every patientfelt frightened with the first hallucination of vision,as is usual with the auditory type, but that if thehallucinations were frequently repeated, self-controlreturned. This again must largely depend uponreassurance by the medical attendant.

MENTAL SEQUELIE OF POISONING.Visual hallucinations may be and are a prominent

symptom, often of diagnostic value, in anothertype of physical disease-that is, in states of toxaemia.Here the hallucinations may be only a part of a generalaltered mental state, for, if the poison is active, thepatient usually soon becomes very confused and mayeven be delirious. Nevertheless, it is important todifferentiate these cases from other types of mentaldisorder, as the mental changes may be veryevanescent, passing quickly away when the intoxica-tion is relieved. In such cases the natural resistancemay be lowered and the tendency of the patient maybe to react by mental changes. It is very necessaryto recognise the syndrome of symptoms arising inthese toxsemic conditions, as, for example, theirpresence may be the first indication of pus. I haveknown several cases where I have been called in owingto mental disturbance and, finding mental confusionwith visual hallucinations and general restlessness, Ihave suggested a search being made for some localisedpus, and on this being subsequently found andevacuated, the patient has made a rapid recovery.Mental disorder is not haphazard in character, andthe better we understand the grouping of its symptomsthe more accurate we shall become in the diagnosisand prognosis of any given case.Now we know that certain persons are hyper-

sensitive to particular proteins and that this hyper-sensitivity may precipitate a mental disturbance. Ihave seen three cases of violent delirium followingupon the ingestion of mushrooms ; in two of themthere was no evidence of the taking of the mushroomsuntil the patients recovered, yet it would have beenunfortunate if they had been certified as insane whilstsuffering from what was nothing more than an

unusual reaction to a particular protein. We are onlyupon the threshold of understanding the effect of anyforeign protein taken into the body, but both clinicallyand experimentally it is recognised that strikingeffects may follow quite insignificant dosage. It mustbe borne in mind that the effect may be more physicalthan mental, or vice versa, and consequently theremust be every gradation between the two, and thoughthe bodily symptoms may be the more common it isnone the less important to seek for and to note anyfunctional nervous change. The following case

illustrates the importance of appreciating mentalsymptoms in their true light and shows their diagnosticvalue.An ex-soldier, who joined the Horse Artillery in

1915 and had passed through three and a half years ofactive war service without suffering from any sicknessor having been in any way injured, was demobilised in1920, and on Oct. 4th of that year went to the WoolwichSection, Bramley, as a shell inspector. On Dec. 21sthe was put to remove fuses, and was then brought

into direct contact with tri-nitro-toluene, commonlyknown as T.N.T., in a pure form. On the 31st hebegan to complain of headache, and as it becamcincreasingly severe, he left his work and walked home.a distance of 12 miles. He stayed in bed but did notsleep at all that night. Next day he saw his medicalattendant, who prescribed for him, but he got norelief from the pain in his head, his memory wasnoted as beginning to fail and he remained sleepless.Restlessness supervened and he gradually becamedelirious ; he was removed to a mental hospital onJan. 4th, 1921, as a person of unsound mind. On the7th I found him suffering from acute mental confusionof the delirious type, clearly occasioned by some poison.The syndrome of symptoms was not that of an ordinaryinsanity and the onset of the illness was entirelydissimilar. Further, he had never had any mentalillness before, neither was there any history of mentaldisorder in his family. There was no evidence thathe had been exposed to any other acute poison. Hisillness followed the course commonly observed intoxic cases ; the headache ceased soon after he gotto hospital, sleep began to return, and by June, 1921,he was quite well.

I mention this case more especially because someopposition was at first raised to the diagnosis on theground that T.N.T. was not known to producemental disturbance. It is known to produce headachesand violent headaches, and if this occasions acutesleeplessness, mental deterioration may take placerapidly in certain persons. Any poison may producemental disorder provided the person who takes orabsorbs it, by his special idiosyncrasy, reacts in thisway. This case is of further value as illustrating thedanger of regarding physical and mental diseases as-inseparate categories according to which group ofsymptoms is the more in evidence. It is true thatthis is done to a much less extent than in former times,but we are not yet free from the pernicious tendency.

GESTURE, EXPRESSION, AND POSTURE.I do not think that I could be charged with mis-

representing the facts when I say that. too little heed isgiven to gesture, expression, and posture. There arewell-recognised diseases in which characteristicchanges in any one or more of these are noted, andthey may constitute important links in the syndromeof symptoms which go to establish the diagnosis ofsuch diseases, but, generally speaking, little or noremark is made about them. Yet to the trulyobservant person gesture-language will convey as

much as, or more than, words, which may be mis-leading; while gesture seldom is, for it is complex,the outward and visible sign of inward sensa-

tion and emotion. Maudsley, in his book on

" Pathology of Mind," says: " What is mind-reading but muscle-reading through movements so fineas to be discernible only to a practised sensibility ?

"

Physicians of long experience acquire it, but it isa matter of too much importance to be left fortime to teach and the student should be trained toappreciate it. He learns that physical pain, especiallyof the visceral type, is shown by the lower part of theface, but the tremor set up by strong and intermittentnerve currents transmitted to the various musclesmay be of almost equal importance. Apprehension.anxiety, depression and pre-occupation of any kindare all reflected by expression and gesture. The manwho can observe can inquire, but he who sees butdoes not perceive is left in ignorance unless theinformation is disclosed to him by the patienthimself. Further, even if noted, evidence ofemotion such as tremor and the like is commonlyexplained away without any real investigation beingmade. Persistent disorder of conduct usually leadsto further inquiry unless it is regarded as purely" hysterical," but owing to the loose way in which thisterm is frequently used abnormal behaviour may bewrongly regarded. The conduct may become un-disciplined, and there may be a general restlessness;this is common in some forms of heart disease, and evencommoner in exophthalmic goitre. Further, these

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may be the first symptoms to attract attention, and inany case they should never be looked upon as

unimportant. Conduct may be disordered either byover-activity or by under-activity ; great muscularresponse may take place with slight stimuli or theinertness may be such that even with powerfulstimulation the response is small, while between thesetwo extremes stand infinite variations. A change ofconduct which originates in the course of some diseasemay persist after the latter has passed away unlesssteps are taken to remedy it, for such a change maybecome a pure habit. If, on the other hand, the patient’sattention is drawn to the symptom, and it is treatedas part of the illness, it not uncommonly disappearsas recovery takes place.

DISORDERS OF THE ENDOCRINE SYSTEM.

Disorders of the endocrine system are at the presenttime attracting most attention as examples of theclose relationship of mind and body. Here the dis-turbance may have its beginning either from thepsychical or from the physical side. Dr. HectorMackenzie in the Bradshaw Lecture which he deliveredin 1916 dealt very fully with the relation of exophthalmicgoitre to mental disturbance, and he showed that notonly was it common, even up to one-third of his cases,to find the onset of the illness preceded by some moreor less severe mental shock or strain, but that markednervous and mental disturbances might arise in thecourse of the disease. My experience fully bears outMs statements and the history of cases which developedduring the late war all goesj to show the closerelationship of nervous and mental processes with thethyroid gland. The stimulation of the sympatheticnervous system and of its coadjutors, the adrenalsand the thyroid, results in a mobilising andrapid expenditure of reserves, and for the timea heightening of all the vital processes. It is a

katabolic action and yet, owing to the quickeningof metabolism, it is at first associated with a feelingof well-being, which may be so strong as to producea mildly exalted state. But, should this continue,exhaustion, with all its usual mental and physicalconcomitants, must sooner or later result. Apartfrom emotion, the feeling tones associated with diseaseare important to note and understand, otherwisethe affective changes in the patient may be seriouslymisleading. One of the most remarkable and yetmost common instances is the buoyancy of spiritsto be observed in certain patients on the days imme-diately following an operation. Although this bright-ness may, to a small extent, be due to the relief ofmind that the ordeal which has been weighing heavilyon the, patient is now successfully past, anothercause, if certain authorities are correct, would seemto lie in the stimulation of the sympathetic nervoussystem and the endocrine glands, one of whosefunctions they say is to protect the organism in timeof stress. Too often one sees this cheerfulness,from whatever cause, misinterpreted, and thephysician or surgeon who looks for a rapid resultwelcomes this attitude as an indication ofreturning health, and all too frequently itencourages him to abandon the rules of carefulnessand to permit his patient to do things which hastenthe onset and increase the severity of the exhaustionwhich must follow. If a patient is depressed or

unduly elated, an endeavour should be made todiscover the cause, and when I speak of these con-ditions, I do not refer to states of melancholia andmania which are usually spoken of as insane conditions.There are many variations in affective tone ; some

may be temperamental and some rhythmic, butothers may be due to metabolism changes. I havelong remarked upon the sense of well-being winch isso commonly associated with a fall in the body-weight ;it is probably one of the most deceptive mentalattitudes found in human life. During the war

many of the civilian population who lost considerablebody-weight owing to the restriction of food com-mented on how much better they were for it; some,no doubt, were better because their reserves were

abundant, but others learned to their sorrow thatthis betterness was ephemeral and that a period ofill-health awaited them.

CONCLUSION.

Time will not permit of my treating this subjectin a detailed way : all that I can attempt to do isto indicate some of the larger groups of disorder.The mental reaction of every person to disease isindividual, though it is always the same for thatperson ; nevertheless, the reaction is not haphazard,but follows rules and progresses in an orderly way,and it is therefore incumbent upon us to discoverthe principles which regulate it. The more elementalthe mind the easier the problem becomes, and forthis reason to study the mental reactions of childrento disease is the most helpful method of approach,for in later life the experiences that an adult haspassed through add their colouring to the fundamentalswhich underlie them. The tendency, or indeed Imight say the universal custom, in the past has beento regard man as he appears ; we have a face-valuestandard of mental and physical health, but wenever rely upon the latter in the way in which weare prepared to accept the former. If we desire tobe exceptionally careful, we examine the bodilyhealth together with the functions of such organsas we consider to be important. If these are satis-factory, the patient is regarded as an A man, notwith-standing that the mental outlook may be scarred withformer illness. There is no better example of thedanger of specialising than the study of mental andphysical medicine; theories become practice, andman has been viewed from these two standpoints,which at some periods have been so divorced as tohave little or nothing to do with each other. Thephysiologist and the bio-chemist have been slowlylinking these divorced subjects together, and it isnow the duty of all clinicians to widen their vision,and not only to make use of the beginnings that havealready been made, but also to add to their knowledgeby a systematic investigation of mind states in allphysical disease. We shall find that mental symptomshave their value and that whilst some are primarilyhurtful others may be largely, if not entirely, pro-tective to the organism and may form part of itsarmament in its struggle to survive. But, as with allfunctional disturbance, they may remain long aftertheir purpose has ceased to exist. Habit is the statetowards which everything is working, and it is oneof the duties of the physician to see that banefulinfluences do not persist if it is possible to correctthem. The physical hygiene of the future mustinclude a knowledge of mental hygiene just as mentalhygiene must-take note of the welfare of the body.From this several advantages will accrue : mentalprocesses will be better understood - and mental

changes will become matter of commonplace ; fearsof insanity will be replaced by an enlightened under-standing, and the incidence of the graver forms ofmental disorder will be lessened.

DINNER TO EMERITUS PROFESSOR H. BRIGGS.-OnOct. 21st Prof. Henry Briggs was entertained to dinner inthe Adelphi Hotel, Liverpool, by his colleagues and friends.A large gathering was presided over by Major MarkRathbone, chairman of the Committee of the LiverpoolLadies’ Charity and Lying-in Hospital, who proposed thehealth of the guest of the evening. The toast was supportedby Vice-Chancellor Adami, Dr. John E. Gemmell-in absentia- Dr. Hayward Willett, Dr. John Hill Abram, President ofthe Medical Institution, Dr. C. J. MacAlister, Mr. RushtonParker, Colonel Barnes, and Miss F. Ivens. All the speakersbore testimony to their high opinion of Prof. Briggs as aman, a scientist, a brilliant operator, and a great organiser,and paid tribute to the splendid work he had done-in estab-lishing and bringing to a high pitch of perfection the depart-ment of obstetrics and gynaecology in the University ofLiverpool. Prof. Briggs thanked the gathering for thehonour paid him, and recounted the many difficulties he hadfaced, and the obstacles he had overcome in an endeavour tosecure adequate opportunities for the instruction of hisstudents in obstetrics, and in making his department in theUniversity one of the finest of its kind in the country.