In accepting the invitation kindly given me in this Journal last October to explain more fully my views on the relations of the nervous system to the operations of consciousness, I feel that I labour under more than one difficulty. The questions raised are not to be solved in the main by experiment, though the biologist of the present day is too liable to take for granted that his science can be forwarded by observation and experiment alone, and that there is no art required to draw just conclusions from these. Then for the most part my statements remain unassailed, and the rôle left for me seems to be principally one of reiteration and re-attack. On one point I cannot too much insist, namely, that to prove one theory false it is not necessary to be prepared with another which is true to replace it. The question whether the prevalent theory is correct must not be confused with any other; and I submit that the objections against the current doctrine of sensation, to which I gave publicity at the Liverpool meeting of the British Association in 1870, remain unanswered, not because they are unknown, but because, as I have found physiologists are ready to own, they are incapable of refutation.

As in France, so in the Netherlands there is but one law relating to the care of persons of unsound mind. It was issued on the 29th of May, 1841, and consequently is posterior by about three years to the French law.

The observations now to be recorded relative to the physiological action of Caffeine upon animal thermogenesis were carried on several years ago as part of a series of experiments in the same direction with numerous potent alkaloids, atropine, solanine, hyoscyamine, strychnine, and others. †

“May good digestion wait on appetite, and health on both.” So speaks the greatest of our English poets—the immortal Shakespeare.

Mental Exaltation, Mania.—The question of the Prognosis in Mental Exaltation—Mania—in its various forms, is a far more debatable and uncertain matter than in melancholia. The symptoms in melancholia being of a negative character due to a lowering or suspension of brain activity, we do not look for all those diversities, endless varieties and aspects which we may find in mania, be it simple, acute, or chronic. Generally there is an increased vitality, a state of hyperæsthesia, an increase in the activity of the brain, generally of the whole brain, and we must believe that these states will not so easily end in complete resolution as the condition of merely depressed action, or rather no action, which obtains in melancholia—I mean in melancholia generally, and not those states of acute melancholia which are supposed to be closely allied to the state which in other brains and under other subjective circumstances would give rise to mania from a pathological point of view. If this increased activity does not rapidly terminate in resolution, one of two things must occur—either exhaustion or atrophy, resulting in death or dementia, will supervene, or abnormal tissue will invade or replace healthy nerve paths or areas, and chronic aberration of mind ensue.

It seems to be generally assumed that asylums were built large, either on the idea that they could be more cheaply constructed or that they could be maintained at less average weekly cost than small ones, but I doubt if such is the true reason of the growth of large asylums, or of the development into large of small ones. Convenience would appear more to have determined the size than any other consideration, a thing not to be wondered at if such large counties as Yorkshire, Surrey, and Middlesex are regarded, where the visiting committees of magistrates are largely taxed as to their time in attending institutions placed often at long distances from each other. But all these considerations of convenience ought to, and no doubt would, disappear if it were abundantly manifest that the outcry raised against large asylums as causing a higher death-rate, lower recovery rate, and heavier weekly charge could be substantiated.

Injuries to self, or rather attempts at their infliction, are events of such frequent occurrence that in certain forms of mental disease their probability is indicated by the symptoms, and due precautions are usually adopted in asylums for their prevention, although no previous overt act may have given practical warning of the tendency.

Some examples of tubercular meningitis occurring in adult insane males will be briefly summarized.

Admitting the difficulties that one has in the classification of insanity, it seems to me, at all events, reasonable that we should recognise classes associated with definite physical changes. Symptoms may be ever changing and deceptive. A patient may to all appearances be weak-minded, but on recovery it may be found that such patient's apparent abstraction and mental weakness were merely the result of an overbearing and overpowering sense of misery, so that, in fact he was suffering distinctly from melancholia, and the mental faculties were in abeyance through the assertion of other painful sensations. A severe grief or an intense occupation of any kind may make one forgetful of his surroundings, regardless of the state of the weather, the time of day, the condition of one's general health, and so on; and so it is that in many cases of profound melancholy there is an apparent arrest of function. This by the way. We have to consider the fact that at certain periods of life there are certain special tendencies to an intellectual breakdown. Any serious affection of the brain in early childhood so affects the as yet undeveloped structure that it totters readily to its fall, and, once having suffered a severe shock, it is with difficulty restored. In the period of adolescence other functions of the body are developed, and with them many stirring sensations are aroused, which have a great tendency to upset the highly nervous and unstable neurotic patient. As life progresses some people exhibit marked tendencies to die out through their nervous systems. Certain persons develope phthisis late in life; others develop cancer, gout, chronic rheumatism, or other constitutional vices. But the thing that interests me most in this consideration is that there are definite forms of disease seen in patients dying out from exhaustion or wearing out of their nervous tissues. As has so often been said, age is purely relative. A man may be a boy at 70 or an old man at 35. Age, from the physician's side, is a relative advance towards decay and destruction of the most important of the vital tissues and organs. A man may have all his organs slowly degenerating before he has reached middle life, the degeneration being due to some constitutional disease, or to some such condition as atheroma of the vessels. In an asylum one constantly comes across patients who have inherited insanity from their parents, and who have inherited a special form of insanity, and even others who have not inherited any special form, but have inherited the tendency which produced the insanity; thus whereas one person has atheroma of the vessels and dies of apoplexy, another has atheroma of his vessels and dies of aneurism, and another patient has atheroma of his vessels and angina pectoris, so that the offspring of these patients may have not only the atheroma of the artery, but either the apoplexy, the aneurism, or the angina pectoris, according to whether the parents had the one or the other. I have seen many cases in which a parent has suffered from mental disease only when he has become 60 or 70, and the children have gone on very well until they reached a similar age, and then have broken down under similar circumstances in a very similar way. It would not be right always to say that this has no relationship to mental effects and to predispositions. One knows that suicide, for instance, is not only associated with a family disposition to nervous disease, but is in many cases also associated with a dominant idea which has from early days been before the patient's mind—that suicide has been, as it were, the evil genius of the family; and so the fact that a parent has died of nervous breakdown has been reported to a patient, or has been remembered by him, and when he comes to a like age he necessarily thinks more about the fate of his parent, and this alone, in some temperaments, might be a cause of producing insanity. In some families it is very noteworthy that a certain age is looked upon as being critical, and if that age be satisfactorily passed, the individual may live to a considerable age beyond, but immediately before this crucial period many members have begun with ailments and have certainly worried themselves into their graves. But what I would distinctly assert is that in certain families the tendency is to die of some affection of the nervous system in preference to dying by any other system; and it is interesting to note that in some of these cases the tendency is not always transmitted in exactly the same way, but that the offspring of such parents, if they have not been placed in otherwise favourable circumstances, may break down earlier in life; and although I am not in a position to assert positively that such is the case, many instances have inclined me to the belief that the offspring of those parents who have broken down, say at the climacteric or from advanced age, are more liable than other insane patients to break down at special periods, such as at adolescence and the climacteric. When one comes to consider the changes that we mean by old age, I should say that the mark I have used as the test as to atheromatous condition of the arteries is seen by the tortuous temporal arteries, and the rigid and rather high-tension in the radial pulse. Other symptoms, such as capillary congestion about the cheeks, white hair, and a tendency to leanness, have, of course, been considered, as well as the condition of the eye called arcus senilis. All the patients to whom I shall refer have the above characteristics, as well as years over 60. They suffer either from progressive dementia, with or without paralysis, or from melancholia of one form or another. As we shall see presently, they suffered from hypochondriacal symptoms, or in some cases exhibited maniacal excitement with exaltation, and I shall have to refer specially to at least one case in which these symptoms were so markedly like those of general paralysis of the insane that I was constantly asking myself in what the difference consisted between our typical cases of general paralysis of the insane and cases such as the one under consideration. We were obliged to confess that if the patient had been brought before us, and that blindfold we had been told that his age was 35, we should not have hesitated for a moment in saying that his was a typical case of the disease. General paralysis does occur in old men sometimes as well as in young men, but it is not nearly so common, and when we meet with these cases wo are obliged to consider them as a special sub-variety of the disease, or else must look upon them merely as cases of degradation of nerve tissue, having somewhat similar symptoms, to the symptoms seen in general paralysis of the insane. I am rather fond of regarding these cases as not truly those of general paralysis, but as examples of progressive nerve degeneration, and I prefer to look upon symptoms of general paralysis of the insane as symptoms that are produced solely by a steady and progressive degeneration of the highest nerve centres; and under these circumstances I would expect that any disease which produced steady, progressive degeneration of these highest centres would also produce similar symptoms, just as in the lung, whether it be a tubercle, a mass of smoke, or a piece of steel or stone that sets up irritation, inflammation, degeneration, and a cavity, the course and symptoms of the disease are the same.

I am indebted to Dr. Rogers for permission to publish the notes of the following case:—

The two cases can only be linked on account of the rapidly fatal issue associated with actively violent mania. The first was a case of acute general paralysis, and the second of mania due to injury to the head.

T. P., an unmarried man, 28 years of age, was admitted a patient of this asylum in October, 1880, suffering from a first attack of insanity.

There can be no doubt that there is a growing feeling on the part of the Medical Superintendents of our large asylums to take into consideration the question whether on the whole the discontinuance of beer as a beverage is not a moral as well as a financial advantage, and it is worth recording in this Journal that at the present time, to our knowledge, there are seven and twenty pauper asylums in England in which the Committees, with the approval of the Superintendents, have discontinued the use of beer as an article of ordinary diet. The question, we need hardly say, is a practical one, and has nothing whatever to do with “teetotalism;” the course pursued should be determined by what is found to be best for all concerned, and if beer at meals is useless—if it can be shown that the health of the asylum population does not suffer from its removal—and if, as alleged, there is a moral gain not only among patients but attendants, then we must acknowledge that common-sense and humanity would alike sanction its discontinuance. For the Medical Superintendent, the health of the patients and the good order of the household are the primary considerations; we must not allow the idea of saving money to interfere for a moment with these objects. If, however, on these grounds we can recommend this dietetic change, the saving to the ratepayers is not a small matter. They are always entitled to consideration, but more especially are they so at the present day. The Cumberland and Westmorland Asylum was, we believe, the first to make the experiment, at its opening, under the superintendency of Dr. Clouston, and the present Superintendent, Dr. J. A. Campbell,∗ regards it with great favour as an unquestionable success. When visiting the Lenzie Asylum, last autumn, we enquired of Dr. Rutherford what plan he adopted, and were informed that he did not give his patients stimulants, although so many are employed in out-of-door work. In December last, the Visiting Justices of the Devon County Asylum decided that at the commencement of 1883 the daily supply of beer should be entirely discontinued, and that in future neither it nor spirits should be allowed unless ordered by the medical staff. On going round the Derby County Asylum in October of last year, we found the energetic Superintendent of that institution had gradually diminished the use of beer, and contemplated its entire discontinuance. This course has now been adopted, and Dr. Lindsay is sanguine as to its satisfactory working. We transcribe the remarks made by him in his last Report:—“In a few years it will probably be found that in the majority of English pauper asylums, beer will not be given as an article of ordinary diet; the minority at present giving do beer will soon, I believe, be converted into a majority. I am of opinion—an opinion, I believe, shared by many Asylum Medical Superintendents—that the small allowance (half-a-pint) of asylum beer of the quality

Although it is certainly no part of our duty to discuss the charges brought against lunacy doctors abroad, while, indeed, we think that as a general rule it is in much better taste to mind our own business, there is the legitimate motive which the discussion of such charges permits, of endeavouring to learn the lesson taught by the failure, if such it be, of laws enacted for the custody of the insane, and thereby seeking to ascertain whether there is any corresponding defect or source of danger in the legislative enactments of our own country. It also behoves the critic of foreign institutions, or of the scandals alleged to occur in other countries, to remember that he may easily fall into the error of forming an erroneous opinion or a harsh judgment from an insufficient acquaintance with all the circumstances of the case.

Want of space compels us to deal this year in a somewhat summary manner with these publications. We are not conscious that anything really important has been omitted, but we have made the extracts and the remarks thereon as short as possible; indeed we have avoided making the latter except where really necessary.

1. Beretninger om den Kjöbenhavnske, den Nörrejyske, Ostifternes og den Viborgske Sindssygeanstalt i 1880.