1. In this inquiry all the asylums of Scotland are regarded as one asylum, and the different institutions merely as different wards of the asylum. A patient transferred from one institution to another is thus regarded as never leaving the asylum, but merely as passing from one ward to another. The words—the asylum—therefore, in this paper, mean an asylum made up of all the asylums of Scotland.

VIII.—Turning from the living mechanism and its energies, to the energies derived from without that move it—the “strings of the puppet”—to use the mechanical phraseology, we come upon another class of words and phrases which are ambiguously used in the “old metaphysics,” but which have a definite and wholly different meaning in studying the organic bases of mental life. These are such words as impression, irritation, suggestion, and the like. I may be permitted to state, somewhat dogmatically, what is now admitted generally, that all changes in the constituent matter of living things result from the operation of physical or molecular energies therein. This being so, the cerebral series of changes involved in mental states of the individual, and constituting the process termed cerebral reflex action, are due to as purely physical causes as those on which spinal reflex action depends. And this is true, not less as regards feelings like corporeal pain, and sensations, than as regards the highest work of the intellectual faculties. This operation of physical energies, however, was not recognised by Marshall Hall and Dr. Carpenter in 1838, nor, indeed, by physiologists in general. One source of the difficulty experienced in doing this is in the imperfect appreciation of what is physically included under the word impression. Thus, an anonymous defender of the views of the eminent physiologists named observes, in 1846, in opposition to my views—

My attention was directed to this case by Dr. Arthur Mitchell, Commissioner in Lunacy, in the course of his official visit last spring. He informed me that it was one of so-called Kalmuc idiocy, a form of idiocy rarely met with in asylums, but nevertheless not really uncommon. Dr. Mitchell pointed out in this case the distinguishing physical characters of this class of idiots. Some of the more prominent of these are obliquity of the eyes and palpebral slits, shortness and flatness of the nose, depression at its root, broadness or squatness of the hands, transverse fissuring of the tongue, shortness of stature, disproportion between different parts of the limbs, smallness of the head, and shortness of its antero-posterior measurements. Certain mental characteristics are said to be very constantly present, and these will be referred to in the details of the case. The peculiarity of the eyes and nose give the face a Kalmuc look, and hence the name.

The name of John Howard stands alone in history as the pre-eminent type of disinterested benevolence, and the tendency of his work has been universally accepted as having less admixture of evil than perhaps that of any other man. Respect and admiration have been lavished upon him without measure; whether by those whose sympathies were naturally with the objects of his commiseration, or by those who simply desired to emulate his singlemindedness and active humanity. There is this peculiarity in his wide reputation, namely, that the criminal as well as the unfortunate have a direct interest in applauding his beneficence; while the good cannot but admire his devotion to the cause of the helpless, and his straightforward simple method. It would be too much to say that he preceded as well as excelled all other labourers in his special field, or that without him prison reform would never have been achieved, or would have been even indefinitely postponed; for a Parliamentary Committee had reported fully on the subject 70 years before, and Mr. Popham was Howard's immediate predecessor in introducing some important practical legislative improvements. But it is indisputable that Howard awakened an enthusiasm on the subject without which it is impossible to say how far those improvements could have been carried; and further—that he was the principal means of the complete exposure of the frightful abuses and defects of prison management which were then so prevalent. The expansion of his indomitable labours to nearly every corner of Europe, while it established England's pre-eminence in the stupidity as well as cruelty of its maladministration, furnished him not only with ample proofs that these evils were almost equalled in some foreign countries, but with many examples and patterns (for instance, in Holland and Switzerland), which he copied and laboured to introduce generally; and added such weight and volume to the public opinion, which he created or converted to his views, that there is no similar movement which has been more widely, energetically, and persistently sustained.

In 1843 the subcutaneous injection of morphia was introduced into this country by Dr. Alex. Wood, of Edinburgh, as a means of treating nervous disease. He found it remarkably efficacious in relieving neuralgia, but believed its action to be almost, if not entirely, local. His results as to the relief of pain have received almost universal confirmation; but subsequent experiments have shown that the drug acts on the nerve-centres, and thus indirectly soothes the pain of an irritated nerve, and not by causing direct anæsthesia of the seat of pain. To Dr. C. Hunter is due the credit of having first demonstrated that local injection is not necessary for the relief of local pain. He employed the hypodermic injection of morphia very successfully in controlling the spasms of chorea, in subduing the excitement and overcoming the sleeplessness of Delirium Tremens and Acute Mania, and in alleviating the restless wakefulness of traumatic inflammation. (His experiments were published in the “Med. Times and Gazette,” for 1859.) Two years later, in 1861, Dr. W. C. McIntosh, now Superintendent of the Perth District Asylum, then Assistant Physician of Murray's Royal Asylum, Perth, employed morphia, subcutaneously, in almost all forms of insanity, and found it, to use his own words, “a sedative to the furious, a calmative to the depressed and despairing.” His observations were published in the “Journal of Mental Science” for 1861; and although this mode of using morphia rapidly became known, employed, and esteemed in many asylums, and by many alienists, the results, so far as I am aware, were published only as isolated notes till Dr. J. B. Ward's paper appeared in the “West Biding Asylum Medical Reports” for 1871.

Passing from the Egyptians to the Greeks and Romans, we proceed to pursue, in regard to these, the same line of enquiry as that which we have already attempted in regard to other nations. Were their habits, their social life, the character of their civilization, such as to lead us to expect that there must have existed among them, in any well marked degree, the clearly recognised causes of insanity ? In this investigation we must carefully distinguish between their early and heroic age and the period of their highest culture and refinement, otherwise we shall fall into the error of comprising under the same term widely different conditions of society, and in the endeavour to compare them with our own—that is to say, modern civilized life—shall draw a totally false inference. The seeds of insanity may have been widely sown among the people of one age, and but sparsely among those of another. We have abundant evidence in the immortal verse of Homer of the general character of the civilization of the Greeks at the period to which he refers—the legendary and heroic age of Greece; not as a state of barbarism, assuredly, but one which we feel differs widely from our own. They were far removed, doubtless, from the savage condition of certain early Greeks, described by Thucydides, marked, as he represents it to have been, by piracy—men falling upon towns which were unfortified and like straggling villages, and rifling them without disgrace, but rather with glory. He adds that in many other respects it might be shown that the Greeks, at the period of which he is speaking, lived in a manner similar to “the barbarians of the present age,” implying by this that their food consisted of milk and what the chase afforded, uncooked, and that they were clothed in undressed hides. To the people who were in this rude condition the remarks we have already made on barbarous tribes would apply; and we can have no doubt that the causes of insanity were then prevalent in only a limited degree.

The relative extent of the causes of mental disease in ancient and modern society is a problem of profound interest. The study of it is one mode of approaching the consideration of the question of questions for medicopsychologists—whether among the peoples of the highly civilized portions of the globe at the present day more persons do or do not become insane than among the nations of antiquity. The inquiry involves the search after and the marshalling of some facts which are not in themselves medical or psychological, but facts, nevertheless, which lead up to the directly medical and psychological result indicated by the title of this article.

There were in Great Britain in the beginning of 1875 about 72,000 insane persons registered and under control. For the care and treatment of these there are at least 6000 paid officials, whose sole duty it is to act as their attendants and nurses. This is reckoning them as one to twelve patients over all, the usual proportion in County Asylums; the numbers less than this in Poorhouses being made up for by the extra number employed in the care of the wealthier classes.

As the Hospitals for the Insane in the United States of America have recently been prominently brought before the medical profession in England, it may not be uninteresting to the readers of this Journal to have a slight historical sketch of what may be called the past asylum movement in the States. I am not aware that this has been given before in any journal or work published in Great Britian. The peculiar difficulties of a new country, peopled by different races, and the constantly disturbing influence of immigration, ought to be borne in mind in this narrative. These difficulties are too frequently overlooked. In a letter I received from Miss Dix two years ago, she writes—“We have an amazing burden in all our charitable institutions of every class of disabled foreigners of all ages and in all stages of feeble or quite broken down conditions of health.”

About this time an attack was made by the Academy della Crusca in Florence on his “Jerusalem.” To violent abuse of himself, of his poem, and of his father and his father's poems, Tasso replied more for his father's sake than for his own, for his heart was filled with one desire, and his chief energies were constantly employed in appealing to everyone of influence or power, to obtain his release from confinement. He wrote to Bergamo a touching appeal, which it is said moved the Council to tears, and they despatched an embassy to Alfonso, petitioning for their compatriot's release and sending Alfonso a present of an inscription relating to the antiquity of the d'Este family, which he was very desirous of possessing. The Duke promised before long to comply with their request, and declared that he only kept Tasso in confinement to try to cure him of his disorder. Perhaps he was influenced too, in some degree, by a fear of Tasso's renewal of language against him at other Courts in the event of his release. At all events Serassi confesses “He would have granted the urgent prayers of so many noble patrons, and set him at liberty with pleasure, but reflecting that poets are naturally ‘genus irritabile,’ and fearing that Tasso once free would revenge himself for his long confinement and his ill-treatment in the Ferrarese Court with that formidable weapon, his pen, he could not bring himself to the resolution of suffering him to escape from his States, without being first assured that he would make no attempt on the honour and reverence due to so great a Prince.” Two years more thus passed—Tasso in constant hopes of being free, able at times to write sonnets gracefully and with his old power; at times mixing more in the world, then apparently withdrawn again from it; weak and suffering in body, and his terrible apparitions and images increasing upon him, his cell appearing full of them. Flames wreathed and twined themselves in it; rats and other animals seemed to him to crawl across the vault of the room. His ears were filled with noises—ringings of bells, clocks striking; in his sleep and even when waking he thought himself engaged in strife with the spectres around him, and asserted that when no person had been in his prison his closets were broken open, his clothes taken from him, his books pulled down and flung about his room, his gloves or letters drawn out from locked boxes at night and scattered over the floor in the morning. In the midst of this distress both of body and mind he believed that “there appeared in the air the form of the glorious Virgin with her Son in her arms, in the centre of bright and glittering clouds.”

There is a general idea expressed in text-books, and more or less freely asserted in practice, but which I shall prove to be a fallacy, that a high-arched palate is so frequently met with in idiocy and imbecility that it may be taken as a sign of their existence. Indeed, when a case of this kind is brought forward the patient is made to open his mouth, under the conviction that a high palate will be found as certainly as a superficial alteration of the tongue in gastric disturbance. We shall see that the connection is an accidental one; and there is, in reality, no relationship between the development of the intellect and the height and width of the palate. If we consider that the bones of the cranium are developed in a different manner from those of the face, and that ossification at the base is complete long before that of the bones forming the palate, it is clear that there can be no primâ facie reason for thinking that because a person has an imperfect brain he should therefore have an imperfect palate; yet such an interdependence is held. It is quite true that a constitutional taint, such as rickets or syphilis, which affects the ossification of the bones generally and the cranial sutures, would probably affect the palatine bones, and hence it is that many idiots and imbeciles are found to have high or imperfect palates: but on the other hand some modifying taint may dwarf the height of the body, may affect the shape of the head to such an extent as to make an idiot of the microcephalic type, and yet leave the palate untouched, perfect in all conditions of width, height, number, quality, and regularity of teeth.

The chief point of interest in the subject to which this paper has reference, centres in the questions where and what was the provision made for the insane in England in the earliest period in which we can discover traces of their custody? As this enquiry at once leads us to Bethlem Hospital, I thought when Dr. Williams, some weeks ago, asked me to contribute a paper to the next Quarterly Meeting of the Association, that it might fittingly occupy a portion of our time this evening.

There is no error in opinion or judgment, no widespread prejudice, so difficult to eradicate or overcome as one that is founded on sentiment, and when the sentiment is a generous one, seeking to make some atonement for supposed injustice done in the past, in thought or in deed, the prejudice will be apt to cling the more tenaciously. “Peace to Torquato's injured shade,” exclaims Byron in his heart-stirring lines—but was this a just apostrophe? Nobly gifted, deeply afflicted and unfortunate though he was, was Tasso indeed injured, as implied, by his fellow man? Most sad and suffering as his life became, we may be committing a deep injustice in asserting it to have been brought upon him by cruelty or even unkindness; and a fair impartial review of his whole life and circumstances would seem to reveal a far different history. This has been most forcibly impressed by reading the pages of one who from the outset seems to have believed in the grievous wrong done to Tasso by Alfonso d'Este, and to have viewed every event by the light of a preconceived opinion; while to one coming without opinion formed to the perusal of these pages, ignorant until then of the course of events, they would seem, we think, strikingly to set forth the very opposite view; the very facts the author brings forward in evidence of his assertions seeming to furnish the strongest indications of a contrary explanation. To any one coming with even a moderate knowledge of mental disease to the study of this sad life, it will surely seem one in which the tendency to, and at length declaration of, this malady can be most clearly traced out from the very early days of Tasso down to the very last hour of his life. This is not to disturb the shade of Tasso, rather to yield it the desired rest; for who would not rather think of him as bowed beneath the weight of a sad inscrutable affliction sent by no mortal hand, than as the victim of cruelty and injustice, which would indeed have been scarcely human in their refinement, but of which we must consider Alfonso d'Este may have been most unjustly accused?

The particulars of the following case may be sufficiently interesting to place on record, as bearing on the morbid anatomy of aphasia, and, further, as illustrating the negative results which follow localised destruction of convolutions posterior to the “Fissure of Rolando.” The patient, an elderly imbecile female, had been an inmate of the Cork District Lunatic Asylum for the last forty-five years. She was invariably quiet and docile, clean in her habits and person, and sufficiently rational to answer ordinary questions addressed to her quite correctly. She spoke slowly, and with emphasis, but always used the right words to express her meaning; and there was never any noticeable defect in her speech, so far as her powers of conversation went. She had a peculiarly long and pointed tongue, which she took a pride in exhibiting, and which she was able to protrude to an enormous extent. There was no loss or deficiency of motor power whatever, and up to some little time before her death her general health was excellent. On December 29th, 1875, she suffered from a severe attack of erysipelas of the face and scalp, which was, however, subdued in a few days by inunctions of mercurial ointment and liberal support. During this time she became extremely dull and apathetic, being with difficulty roused; but on being pressed could still answer questions rationally. As the erysipelas passed away she returned to her former condition, being quite as well and as intelligent as before.

The importance of microscopical observation as an adjunct to the study of disease is so very obvious that few can possibly deny its value. The great advancement that has been made in pathology, by the aid of the microscope, during the last few years, has almost completely changed most of the ideas that were formerly held as to the nature, prognosis, diagnosis, and treatment of many diseases. Diseases which were formerly shrouded in obscurity as to their real nature, are now clearly defined; we are enabled to trace the fons et origo of the causes which have been at work insidiously undermining the constitution, destroying gradually and surely important organs. We are enabled to employ a more certain means of diagnosis by discriminating structures from one another, which, to the unaided eye, seem alike—thus forming a more sure prognosis. Pathology has, in fact, become a new science by the aid of the microscope. And as microscopical observation becomes more complete, as better means of differentiating structures are discovered, while microscopic objectives are made of more perfect definition, so will the study of histology, and consequently pathology, rank higher and higher, till at last its place may almost, if not entirely, be raised to that of one of the exact sciences. The microscopist does not deal in hypothetical abstractions, but in demonstrable facts; truths which it is impossible to dispute, except from errors of observation. These errors are, however, in some cases formidable, for so many circumstances arise tending to obscure observation. Hence, there is a great necessity for co-operation in the work of histology and pathology, in order that these errors may be seen and understood, then grappled with and overcome. Observers must be willing to work more in unison, to compare results, to submit their work to the severest criticism possible: until they do so the science of histology will only slowly progress towards exactitude. More labourers, too, are needed; the field is so vast, time is so short, that the few earnest ones at present at work are not sufficient.

The disheartening aphorism, in which Hippocrates summed up the experience of his life—“Art is long and life is short, the occasion is fleeting, experiment is dangerous, and judgment is difficult”—is more true of the study of insanity than of any other department of medicine. Were any proof needed of this, it would be sufficient to point to the classification of mental diseases, the symptomatological plan adopted until recently corresponding to the earliest nosology of ordinary medicine, while the schemes which task the ingenuity of a Skae or a Bucknill have a great likeness to the “Phthisiologia” of Morton, or to the nosologies of Sauvages and Cullen.

The short notes which I am going to bring before you refer more directly to the power of repair of bony structures and soft tissues in fractures and wounds, occurring in cases of insanity; and I have the less hesitation in calling your attention to the subject, because I see by the last “Commissioners' Report” that during 1874 twenty-six fractures occurred in the Scotch Royal and District Asylums. I hope, therefore, to hear some useful remarks on the subject from the members present.