Gentlemen,—My first duty is to convey to you my grateful appreciation of the honour you have done me in placing me in this chair. I am not unmindful of the great names which, in the course of more than half-a-century, have gone to make up an honourable tradition in the history and work of our Association. That tradition has assuredly lost none of its dignity whilst in the keeping of Dr. Conolly Norman, our retiring President, who has just now placed in my hand the “hammer” of office.

The object of this paper is to present in concise form recent views upon the influence of Reflex Stimulation and Toxic Agencies upon Insanity and Epilepsy. For the most part these will be dealt with together, although the influence of reflex irritation will of necessity be chiefly confined to epilepsy. With regard to both insanity and epilepsy, cases will occur in which it is impossible to decide whether a reflex or toxic condition originates the mischief. It must not be supposed that these views are novel, except in their development. Both Abercrombie and Henry Monro long ago discussed these theories. The latter acute observer, in his “Remarks on Insanity” (1851), dwells at length on both toxic and auto-toxic origins of insanity, and his views even at the present day may be considered with interest and advantage. Since this time there has been a continual increase of experimental and clinical evidence lending support to the theories advanced. It is the purpose of this paper to state dispassionately the accumulated observations upon this subject. Some apparent contradictions arise at the outset; amongst these are—

(1) Any given disorder may survive the removal of its supposed cause.

(2) Given in two different cases the operation of precisely similar morbid conditions, the same results are certainly not invariably met with.

It was first demonstrated on a large scale, by what was observed in the “Insane Colony” at Gheel, in Belgium, which, some fifty years ago, began to attract the attention of those engaged in lunacy administration, that a large number of the insane may be suitably provided for in private dwellings. It is now more or less widely recognized that in many cases they can be provided for in this way better than in asylums; and as regards the insane poor that they can often be thus provided for in a way not only conducive to their own welfare, but also at less cost to the public. This fact has received its most complete and systematic recognition in the lunacy administration of Scotland. Practical effect has been given to this recognition in various ways both on the continent of Europe and in America. One of the most recent and important steps in this direction has been taken by the authorities of the great city of Berlin, and it is proposed to give an account of what has been done by the Berlin authorities in the following paper.

As it is just twenty years since I first became connected with this asylum—a considerable slice out of what should be the most active part of my life, and the period during which my judgment ought to be maturing—it occurred to me that a résumé of the changes and new departures which have been made here during that time, together with a statement of the views I now entertain of their utility, and the opinions which experience has led me to form for my future guidance, might not inopportunely form the subject matter of a paper this afternoon.

The Supervision and Management of the Patients in Private Dwellings.

The way in which the boarding-out system is administered at Berlin is the result of experience. Its present form differs in some respects from the arrangements made at the commencement of the experiment. It is unnecessary to describe the gradual evolution of the system, the way in which cumbrous regulations were eliminated, and in which greater efficiency was given to the arrangements; but it is proper to recognize the great capacity as an administrator which has been shown by Dr. Sander, to whom, as director of the asylum, the development of the system has been chiefly due.

Up to the present time the experimental movement in psychology has been directed chiefly to the study of methods by which mental phenomena may be subjected to exact investigation, and by which they may receive for purposes of comparison some kind of quantitative expression. So far as these methods have been perfected they have been directed mainly to the investigation of general psychological laws, and of the relation of psychological to physiological processes. Comparatively little has been done in the way of application of these methods to elucidate practical questions; little attention has been paid to individual psychology and to the exact nature of the differences which distinguish the various types of normal and abnormal mind. The more theoretical work of experimental psychologists has naturally a great interest for students of insanity, and must affect their conceptions of abnormal mind, but the special question which I intend to consider is of a more direct and practical kind, viz., the possibility of using the methods of experimental psychology to help directly in the study of the problems of insanity.

The following analyses were undertaken with the idea that the results obtained from them might throw some light on the cause of the seizures or fits that generally occur in the later stages of general paralysis.

The degenerative changes in the tissues of lunatics are more or less well known, at any rate the grosser or naked-eye lesions that are to be expected, but even amongst these there are some points that, I venture to think, may receive further attention. Of histological changes we can say more positively that much light may yet be thrown on their nature. As to their cause—the cause of the degeneration of nerve cells, for instance—we are lamentably ignorant.

I believe it is an absolute matter of fact that at the present time different physicians, both in private practice and in asylum practice, use different methods in regard to their newly-admitted patients, as far as in their treatment rest and exercise are concerned. I do not recollect that we have discussed this important question, nor do I recollect any definite paper on the subject by any competent authority. It therefore seems clear that the subject is one which demands our consideration.

The asylum of Meer-en-Berg is pleasantly situated on a sandy plain close to the village of Bloomendall, within three miles of Haarlem, on the immediate borders of the Great Sand Dunes of the east side of North Holland. This plain, which extends more or less to the North Sea, is supposed to be one of the ancient mouths of the Rhine, now filled up, and close beside it is the ruin of the large castle of Brederode, the seat of the once powerful Counts of that name.

Notwithstanding all the elaborate researches that already have been conducted upon the cerebellum, much controversy yet exists as to its physiology, and a complete account of its functional relations, with the rest of the central nervous system, cannot yet be given. Rapid strides have been lately made, and many doubtful points elucidated by direct experiment upon lower animals, but the deductions drawn from them cannot be regarded as absolutely applicable to man until they have been confirmed by pathological observations on the human brain. With this in view, the case about to be related has been thought worthy of publication.

One of the best and latest descriptions of the functions of the thyroid gland is that by Victor Horsley.∗ This paper furnishes an account of recent work on the subject, and so fully details the results arrived at by other workers that I use it as my chief reference throughout this paper.

As a rule general paralysis is characterized by well-defined spinal symptoms and pathological changes, and, looked at from this point of view, the cases which pursue what may be called a normal course group themselves broadly into two fairly-defined but unequal divisions, presenting more or less distinctive features as regards onset, course, duration, and pathology. The type which is associated with locomotor ataxia is a well-recognized one, and it appears to me that in all the other cases the features which predominate during the progress of the affection indicate a correspondingly close relationship, clinically and pathologically, with that variety of spinal disease termed primary spastic paraplegia. In a small proportion the features are indicative of a combination of these two types, but it will be found that primarily such cases belong to one or other group, the combination of symptoms being of relatively late occurrence.

There is at the present time great need of more complete and definite knowledge as to the pathology of the very marked structural changes that so commonly affect the pia-arachnoid in the insane. The subject is one of much importance to all of us as medical psychologists, for not only is the condition in question one of the most conspicuous lesions associated with mental disease, but it implicates a structure of primary importance in the economy of the central nervous system. It is by way of vessels that course through this membrane that nutriment is conveyed to the brain cortex, and the waste products resulting from metabolism in the cerebral tissues are mainly conveyed away in the fluid that circulates in its lymph spaces. Therefore it is evident that these morbid changes may very seriously interfere with the functions both of nutrition and excretion in the brain.

The subjoined notes are those of a case mentioned at the Association's meeting at Worcester, in connection with Dr. Bond's paper.

Within recent years we have experienced a marked advance in our knowledge of tuberculous disease. We are now in a position to consider its varied phases from a scientific standpoint and to recognize its influence in the course of other maladies the pathology of which may be less obvious. Its relation to mental disease has engaged the physician's special attention for many years, and even prior to the organization of psychological medicine the intimate association which is now acknowledged to exist between tuberculosis and insanity was well known to contemporary writers. It has, however, been reserved to recent authors to classify the symptoms and signs which may guide us with tolerable accuracy to diagnose a case of phthisical insanity by the character of the mental disease coming under our observation.

In a paper I had the honour of reading before you last December I called attention to the high percentage of patients who died of general paralysis of the insane showing post-mortem signs of disease of the kidney. The task I then set myself was to find out, if possible, what was the pathological relation between the two. The arteries seemed to me to be the only connecting link. I then proceeded to point out that a diseased condition of the cerebral arteries occurred in those dying with granular kidneys, very similar to, if not identical with, what is found in those dying of general paralysis of the insane. And, finally, I called attention to three possible explanations of this apparent relationship.

In the “Journal of Mental Science,” January, 1895, I published the results of thyroid feeding in thirty cases of insanity. Since then we have treated at least sixty cases at the Royal Edinburgh Asylum.

Perhaps one of the most difficult investigations possible is the study of the mental characteristics of savage and semi-savage races, and, before formulating any theories regarding their psychic history, it is necessary that a careful study should be made of their mode of life, their normal mental state, and such folk lore as is accessible to us.