The first and one of the most important questions to be determined in dealing with the subject of insanity is the meaning which we ought to attach to the word insanity itself. The condition which the word is supposed to indicate has most important relations, both social and scientific. It is a frequent subject of popular discussion, and it forms an important element in many enquiries—philosophical, medical, and juridical. Speaking generally, it may be said that it invariably signifies a marked abnormality of mental condition. But it is frequently necessary that we should be able to form a much more precise idea of the degree as well as the kind of abnormality that it implies. And a very superficial examination is sufficient to show that the degree and the kind vary greatly, according to the point of view from which the subject is regarded.

Gentlemen,—At various times since you did me the honour to elect me your President for the coming year, I have considered what should be the subject of the address which custom demands that I should this day deliver. You have listened to addresses on the prevention of insanity, the treatment of insanity, the care of the insane whether recent or chronic—in fact, as every year brings its address, I felt that it was difficult to choose a theme that had not already engaged the attention of far abler and more experienced Presidents. When, however, the Parliamentary Committee, which has so long been sitting, commenced its labours, and heard the evidence of so many witnesses on the various points which they have brought before it, it seemed to me impossible that I could pass over such an event without notice, and I determined to lay before you some remarks on the Report of that Committee, and the evidence there received. Yet, although the Committee commenced its sittings in the beginning of March, it has not yet presented its report, consequently I am not able to lay any portion of the latter before you on this 2nd of August.

I.—“I believe,” says Professor Tyndall, “that all the great thinkers who have studied the subject are ready to admit the following hypothesis, that every conscious act, whether in the domain of the senses, of thought, or of emotion, corresponds to a certain definite molecular state of the brain; that this relation of the physical to consciousness invariably exists, so that, given the state of the brain, we may deduce from it the corresponding thought or feeling; or given the thought or feeling, we may deduce from it the state of the brain. But how to make this deduction ? At bottom it is not a case of logical deduction; it is, in fact, a case of empirical association. It may be replied that very many of the deductions of science have this empirical character; such is that by which it is affirmed that an electric current circulating in a given direction will make the magnetic needle deviate in a definite direction. But the two cases differ in this, that if the influence of the current upon the needle cannot be shown, it can at least be imagined, and that we have no doubt whatever that ultimately the problem will be mechanically resolved, while we cannot even picture to ourselves the passage from the physical state of the brain to the corresponding facts of feeling. Let it be admitted that a definite thought corresponds simultaneously to a definite molecular action in the brain. Well, we do not possess the intellectual organ, we have not even the rudiment apparently of the organ, which would enable us to pass by reasoning from one phenomenon to the other. They are produced together, but we know not why. If our intelligence and our senses were perfect enough, vigorous enough, enlightened enough to enable us to see and to feel the actual molecules of the brain; if we could trace all the movements, the groupings, the electric discharges, if they exist, of these molecules; if we knew perfectly the molecular states which correspond to this or that state of thought or of feeling, we should be still as far as ever from the solution of the problem: what is the connection between this physical state and the facts of consciousness? The abyss which exists between these two classes of phenomena will be always intellectually impassable. Let us admit that the feeling of love, for instance, corresponds to a spiral movement of the molecules of the brain to the right, and the feeling of hate to a spiral movement to the left, we should know that when we love, a movement is produced in one direction, and that when we hate, a movement is produced in another direction; but the why would remain still unanswered.”∗

Most of our readers are aware that on the 12th February, 1877, on the motion of Mr. Lewis L. Dillwyn, M.P. for Swansea, a Select Committee was appointed by the House of Commons, “To enquire into the operation of the Lunacy Law, so far as regards the security afforded by it against violations of personal liberty.” That Committee consisted of Mr. Stephen Cave, chairman, Dr. Lush, Mr. Woodd, Mr. Ramsay, Mr. Leighton, Mr. Tremayne, Mr. Herschell, Mr. Goldney, Mr. Joseph Cowen, Mr. Kavanagh, Mr. Butt, Mr. Birley, Mr. Hopwood, Sir Trevor Lawrence and Mr. Dillwyn. It was generally understood at the time, and came out more clearly in the course of the enquiry, that the chief reason for the appointment of this Committee was the fact that strong statements as to the inefficiency of the present Lunacy Acts for the protection of the personal liberty of sane people had been confidently made and most industriously circulated among the public and Members of Parliament by a few persons and a small society, who said they could produce facts in support of their statements. It was generally understood at the time, and came out also during the enquiry, that most of those persons had had personal experience of the deprivation of personal liberty authorised by these laws. It certainly could not be truthfully said that there was any kind of public excitement on the subject of lunacy, or any public demand for an enquiry, nor had any lunacy cause célèbre occurred recently to draw attention to the subject. To most persons engaged in administering the Lunacy Laws, the appointment of the Committee came as a surprise, and most of them, at least in the provinces, did not look on it in any kind of serious light. We fear they thought of it chiefly as a sop thrown to satisfy a few noisy importunate lunatics who were at large, so that few of them offered their evidence, or made any preparation to lay the results of their experience before the public. To this is due the fact that the non-official persons who gave their evidence before the Committee seemed to have been taken quite at hap-hazard, and that there was no proper representation of the different classes of persons who administer the Lunacy Laws, or have to do with lunatics throughout the country. Far too many of certain kinds of people were examined by the Committee, and far too few of others. This is self-evident when, in looking over the list of witnesses, one finds that 17 out of the 59 witnesses were Government officials; that out of the 26 members of the medical profession examined, all but three were specialists, and 14 were London men. The medical profession in general, apart from the specialty of psychiatric medicine, were as nearly as possible unrepresented, for only one of the three of their body was examined on anything but special points connected with individuals. And this in an enquiry as to how the Lunacy Laws affect the liberty of the subject, when 180,000 people have been certified insane and their liberty taken from them by the general body of the profession, under the authority of the Lunacy Act of 1845 ! of that great body of medical officers of unions who certify nearly all the pauper lunatics, not one was brought before the Committee. Out of that most intelligent, public-spirited and large minded body of country gentlemen who compose the Committees of Visitors of the County Asylums, and who have had the whole labour of carrying out the Lunacy Acts in the English Counties, only one was examined on any general question. Not a single Visitor of a provincial licensed house was called to be examined as to how their work was done. Not a single independent representative of the legal profession, which has practically so much to do in carrying out the Lunacy Acts and managing the property of the insane, was asked to give his evidence. The whole body of Poor Law Guardians, who levy the lunacy rates, and represent the public as regards their expenditure, were conspicuous by their entire absence. One might have thought that a few really recovered lunatics could have been got to give a true and impartial account of their treatment while insane. As for Ireland, not a doctor but Inspector Nugent, not an official of any Asylum, public or private, not a governor of an Asylum, not even a half-cured Irish lunatic, appeared to tell how the insane of that country are treated. Scotland was represented by its two Medical Commissioners, and one asylum physician from the provinces. Surely one or two of the Sheriffs, those all important officials by whose signatures every lunatic in Scotland is deprived of his liberty, might have been got to speak for themselves as to whether they acted “ministerially” or “judicially;” and whether they read the doctors' certificates through or not, before they signed their orders.

Criminal Lunacy is a many-sided subject: but I have no intention here of entering upon it from any special standpoint, whether social, legal, or medico-psychological. I merely wish to recount, briefly and without detail, such general matters of interest connected with successive methods of dealing with criminal lunatics as can be linked together in the form of a historical sketch, which does not pretend to be a criticism.

The aim of this paper will be to endeavour to show that neighbours of public asylums for the insane—occasionally using the term neighbours with some latitude—may, under certain circumstances, contribute to the well-being of selected patients, by services of various kinds; moreover, that not only residents in the vicinity, but also friends at a distance, may have a share in alleviating the affliction, perhaps even of promoting the convalescence, of inmates of these hospitals. Among 65,000 persons approximately computed as the number of patients in asylums and other institutions, there are many who are absolutely friendless and unvisited. Some come from distant counties, or even from foreign countries, beyond the range of practicable visits; others have outlived their relatives and friends; or these have, in course of time, discontinued their intercourse; others, again, saddest case of all, are perhaps deliberately deserted, purposely shunned, from selfish apprehension lest responsibility of maintenance or of assistance should be incurred, or from reluctance that their acquaintanceship with an inmate of a lunatic asylum should become known. So, from one cause or another, there are not a few patients who become, abruptly or gradually, cut off from communication with the outside world, practically forgotten as “dead men out of mind.” Yet, in many of these, there must surely exist yearnings after sympathy and that disinterested friendship which, “all for love and nothing for reward,” would take a personal interest in themselves.

I feel that an apology is almost needed for introducing the subject that I bring before you to-day—that of the best means of providing for the care and maintenance of the large and constantly increasing number of pauper lunatics of the demented and imbecile class, which gradually accumulates and fills up the available space in our County Asylums; often to the exclusion of recent cases requiring immediate medical care and attention.

In asylums, we are used to find but small changes in the nervous centres in our dead patients, and these changes are often of so general a character, that no assistance is given towards clearing up the question of localisation of function in brain-centres.

Lecture II.—Insanity in the Middle Ages.

We have attempted in the previous lectures to obtain some idea of the way in which insanity was regarded, and the manner in which the insane were treated up to the beginning of the eighteenth century. We have found that a large number of those who would now be regarded as insane had been, up to this time, either disregarded altogether, or looked upon as exercising supernatural powers of evil, or as inspired with beliefs which were dangerous to the State. Three circumstances seem to have been the chief influences that tended to prevent persons labouring under mental disease from being treated with the consideration due to that affliction, or often with any feeling that they were worthy of sympathy or requiring to be cared for. These were pointed out to be (1) the character of the social system in ancient times—powerfully affected as it was in every detail by the existence of slavery; (2) the political exigencies of communities both in ancient and mediaeval times—so seldom in prolonged possession either of the external peace, or of the internal tranquility necessary for the development of philanthropy in a government or a sense of social duty in a people; and (3) the superstitious ideas arising from ignorance—under which abnormalities of mental condition were attributed to self-induced possession by the devil or to other criminal conduct or supernatural association. In the beginning of the eighteenth century, however, these conditions had either been abolished or had perceptibly diminished in power and importance. Slavery no longer existed in Western Europe; civil administration appeared to have developed into stronger and more stable forms; and owing to the diffusion of knowledge that followed the invention of printing, the grosser kinds of superstition were rapidly dying out.

In a paper on “The Physiology of Mind in the Lower Animals,” in the Journal of Mental Science for April, 1871 (p. 79), I endeavoured to prove that other animals than man possess the same kind of moral and intellectual endowments and apply them to the same practical purposes that he does. The object of the present paper is to show that Mind in the lower animals, or certain of them, is liable to be affected by the same causes of disturbance—is subject to the same forms of defect or disorder—as in man.

It has long been well-known that the curability of cases of insanity diminishes rapidly as the duration of the disease increases. In this respect it follows a parallel course to all other diseases, and indeed to every other evil under the sun. I do not propose in any way to object to this fact, or to dispute the accepted measure of the relation between duration and curability. The object I have in view is to call attention to one or two very grave fallacies of almost equally wide acceptance in the supposed application of this well-known relation. One meets everywhere with the statement that a large proportion of the patients sent to our County Asylums suffer from mental disorder of considerable duration, say over twelvemonths—so far true—but it is added that these cases ought to have been sent to the asylums when recent, in which case a large proportion of them would have recovered, and the accumulation of chronic cases in asylums would be largely or completely checked. All this sounds very logical, but as I propose to show, it is quite untrue, and to those who are well acquainted with the fact, must be so obviously incorrect, that one is surprised to meet this statement in various forms in a very large proportion of the reports of Medical Superintendents of Asylums, in Medical Journals, and elsewhere; nor do I recollect seeing anywhere a hint as to the erroneous use of statistics on which it rests. I cannot, perhaps, give a better view of the remarkable and erroneous opinions to which this error leads than by giving in full a recent instance from a leading Medical Journal of the deductions drawn from it.

The term used above is, I believe, new to medicine, and I introduce it as convenient to denote the treatment of insanity, or, indeed, of nervous diseases generally, by the means of coloured light.

There is probably no disease to which human flesh is heir that attracts, every now and again, such a degree of public attention—that begets such a keenness of personal dread—that so frequently forms the subject of sensational narrative or comment in the public press—that causes to be exhibited so disgraceful an amount and kind of ignorance, superstition, credulity, and cruelty—as hydrophobia. Even cholera is not so formidable a disorder in the public esteem. Its cramps are not always present; and when they are, they are not comparable with the convulsions of hydrophobia. Nor is there any terrifying mental disorder in the case of cholera; whereas, in hydrophobia the morbid mental phenomena are more prominent, serious, and impressive than the motor ones. Moreover, cholera is not popularly believed to be necessarily and in all cases fatal; whereas it is currently supposed that there is no chance of escape from hydrophobia.

In this communication it is proposed—

(I.) To relate three cases of general paralysis in which localized copious perspiration affected one side only of the face and head, and to mention a fourth case in another insane patient.

(II.) Next to refer to some other cases of unilateral sweating mentioned by authors, but not occurring among the insane; and

(III.) Lastly, to speak of the pathology of this symptom. I. By reference to the subjoined notes, it will be seen that the unilateral perspiration of the face occurred under dissimilar conditions in the three cases of general paralysis; in one, without any local paralysis or convulsion, but associated with old-standing disorganisation of the eyeball of the same side; in another, occurring sometime after a peculiar change in the mental state, and at first with very slight and very transitory unilateral facial paralysis; while in the third the unilateral perversion of secretion accompanied unilateral convulsions and hemiplegia of the corresponding side. All these patients were soldiers.

Six years ago I endeavoured to show, in a paper read before a quarterly meeting of the Medico-Psychological Association,∗ that there were not sufficient reasons to warrant the popular opinion, shared by some who had done more than accept a common notion without inquiry, that insanity was steadily increasing upon us year by year in this country; that, in fact, the undoubted great and rapid increase in the registered insane population of England was in the main to be attributed to other causes than an actual steady increase in the production of insanity. As the result of the enquiries, it seemed very uncertain whether we manufactured more madness now than formerly, but very certain that we take more care of, and know a great deal more about, the madness which we do manufacture.

The occurrence of transient hemiplegia is so unfrequent in nervous affections, and the pathological conditions causing the symptoms are so obscure and uncertain, that any additional information regarding the nature of the lesions in such cases is of importance, and so I venture to bring before the Society the following case:—

A. M., æt. 73. Widow. From Edinburgh. Was admited into the Royal Edinburgh Asylum on October 10th, 1873.

In the “Journal of Mental Science” for April, 1876, a short account appeared of the present state of the Irish Lunatic Asylum Service and the action then being taken by Irish Medical Superintendents to obtain a more secure footing under Government, by ranking as Civil Servants. In order to gain this object, it would be necessary that the Executive should become their paymasters, and that their salaries, instead of coming from the rates, should be paid by the Treasury. Once secure of their position as Civil Servants, the rest would follow; their services would reckon, no matter how often changed from one asylum to another; they would no longer hold the anomalous position of men appointed by Government, responsible to central authority but paid by the ratepayers and as Civil Servants they would come under the Superannuation Act of 1859. Above all, they would become more closely connected with the Government, and obtain greater support and assistance in their official duties and in their attempts to further the study of mental disease in Ireland.

I.—It is well known that the very different death-rates obtaining in different asylums depend much more on the different classes of patients they contain, than on any differences in the hygiene, or other conditions of the asylums themselves. Very little has, however, been done to obtain any accurate measure of the mortality rates that obtain amongst different classes of patients. The statistical tables of this association, which have now been used in the annual reports of asylums for a dozen years, contain much material that may be used for elucidating the matter. It is somewhat surprising that the valuable statistics contained in these tables have not been made use of to any extent either for this or any other purpose; the impediment, probably, is the considerable labour involved in any extensive analysis of their numerous data.

Many of the well-known pathological appearances found in the brain in insanity will, I doubt not, be found to have much more significance than they are thought to have at present, when the general physiology and pathology of the organ is better understood. It cannot be that such serious and enduring marks of morbid action in the parts supplied by the internal carotid and vertebral arteries as thickened and condensed cranial bones, adherent and thickened membranes, congested and toughened vessels, pia mater adherent to convolutions, and atrophied convolutions; all appearances, one or other of which are found in the majority of the insane, and treated almost as matters of course in the asylum dead house—could have arisen without intense disturbance in the working of the delicate neurine that those structures envelop and subserve. We as yet don't fully know what those things mean, as regards the previous condition of the brain. We talk of over-action, congestions, and brain excitement, but such terms are but vague expressions when we closely analyse what they mean. I think we are entitled to conclude that if such things are the accompaniments and effects of the storm on the bulwarks and sails of the vessel, the state of matters in the ship itself, while the tempest was at its height, must have been disturbed enough, could we only have had the means to see it. I have scarcely any patience in arguing with those who will say that there are no pathological changes left in the brains of those who have died insane, when such things are commonly met with, and can be seen by any tyro. It is our capacity to draw conclusions from such things that is at fault; and our means of observation as to the real condition of the minute brain structure. Conceive what dynamical disturbances must have occurred in the working during life of a most highly organised, yet infinitely delicate, jelly-like convolution supplied by a twig of a meningeal artery, during the long period when that twig was becoming thickened in its coats, overstrained at one time by intense congestion, its perivascular space alternately blocked up by débris, and by the overloaded vessel, its blood current now rushing at twice its usual speed, and then in a state almost of stasis. It is vain for anyone to say that such conditions can lead to an organic alteration in the coats of the vessel, and yet that the neurine may be left normal. The fact that all those vascular disturbances and changes were, probably, the result of the morbid vital action in the nerve tissue, and not its cause, were the result of the mere straining of the supply pipe from the irregular demands of the part supplied, should make us realize very vividly the intensity of the pathological disturbance that goes on in the convolutions of a brain that is acutely maniacal.