Gentlemen,—I cannot commence my address without reminding the Association of the regrettable circumstance which has resulted in my having had conferred upon me the honour of occupying this position to-day.

It will be well known to all to whom these remarks are addressed, that Statistical Tables of the Causes of Insanity in the Admissions into Asylums began to be collected by the English Commissioners in Lunacy for the first time in 1876. In that year returns upon a definite system and plan were asked for and received from all asylums throughout England and Wales, the results being published in the Commissioners' Blue Book for that year. In the following year, 1877, the corresponding statistics were not collected, but in 1878 they were resumed in a slightly modified form as regards the list of causative agencies from that originally issued, and, on the amended plan, they have since year by year been continued.

Before approaching the next subject I wish to avoid the reproach of departing from the rules of the inductive method by drawing conclusions from the complex to the simple; that is to say, in this case, by applying to the lower centres a conclusion drawn from the observation of the higher centres, instead of proceeding in the opposite way. I am obliged to proceed in this manner by the very nature of the problem which really cannot be treated any other way. As we have to deal with the subjectivity of central phenomena it is impossible to seek its conditions when we have no direct means of proving its presence or absence. Now in respect to the subordinate centres we are reduced exclusively to objective observation, which in no way can teach us anything of the subjectivity of the changes which take place in them; therefore, whatever conjectures we may make in regard to the consciousness or unconsciousness of the motor reactions furnished by the lower centres, they can have only a certain degree of probability when we study these reactions by the aid of what subjective observation teaches us relative to the consciousness or unconsciousness of the cortical centres. It is because they have not followed this method that writers disagree so completely as to the presence or absence of subjectivity in the sensori-motor centres, and especially in the spinal cord. Let us begin with the latter.

“Il n'y a point de parité entre la responsabilité d'un médecin et son pouvoir; l'une est grande et l'autre petit, et c'est justement à cause des limites oò ce pouvoir est resserré que, bien qu'il soit facile d' en laisser perdre une parcelle, la moindre parcelle perdue cause une poignante anxiété.”

During the year ending 1883, I had rather an unusual number of escapes, and as two ended fatally from exposure, I thought it only fitting to glance over the escape-book and see the results of previous years. I may here mention that the two patients who died were dements, that one had been 17 years in Garland's Asylum, the other 15, that neither had shown a disposition to escape previously, that one died after two days' exposure, he having been found alive, and that the body of the other was found seven days after his escape; also that all means likely to be of avail in retaking these patients were made use of.

At a time when Insanity is commonly looked on as a bodily disease; when the only aspect of it that receives systematic study is that of disturbed bodily function; when a leading neurologist speaks of the mind as “a force evolved from the brain; when the main difficulty in the exposition of the facts of insanity lies in procuring an acknowledgment that there is anything besides the bodily health to be studied; little insistence need be laid on the importance of a systematic and methodical examination of the condition of the bodily functions in cases of Insanity.

In the “Journal of Mental Science” for April, Dr. Alexander Robertson has referred to some observations of mine on the effects of galvanism in the treatment of insanity. These observations were made more than ten years ago. The cases chosen were not quite suitable or satisfactory; they were few in number, and the treatment was not thoroughly carried out. Still the results were far from being unsatisfactory; in fact they alone were quite sufficient to satisfy me that electricity, if properly and perseveringly applied in suitable cases, is a powerful means of cure. I am confirmed in this opinion not only by the results of these crude experiments, and others more recently and more carefully performed, but also from the value of electricity in other neuroses to which insanity is analogous. There are few who can deny, at least reasonably deny, that such neuroses as paralysis, chorea, neuralgia, anæsthesia, &c., are benefited in a most decided manner by electricity. There are forms of insanity, as all authorities on the subject affirm, which seem, if they really are not, identical with these neuroses, and it is not at all preposterous to assert that if it does good in one form of nervous disease it must do good in the other.

While the condition of the blood vessels in General Paralysis has been a subject of discussion by many observers, and the state of the pulse, including sphygmographic tracings, has engaged the attention of Thompson and others, I have been unable, in the literature to which I have had access, to find reference to any observations on the state of the blood in this disease.

The feeling of the sacredness of human life, which springs from the selfish feeling of the sacredness of the life of each person to himself, has extended in many directions, so that the murderer's life is often spared, and the suicide is considered as not responsible for his acts.

According to the latest returns, published by the Commissioners in Lunacy in their Blue Book for 1883, sixty-seven thousand four hundred and eighteen patients were registered as under treatment in the various asylums of England and Wales, and as being under private care during the previous year.

The question of the relation between Uterine Disease and Insanity is one which, though at different times it has attracted much attention, is yet very far from being thoroughly elucidated. On the one hand the subject is mixed up with so-called “Hysterical Insanity,” and on the other with “Amenorrhœal Insanity,” concerning the former of which it may be said that but little evidence has been advanced to prove its dependence upon distinct physical disease in the internal organs of reproduction; and, as regards the latter, it needs but little observation in an asylum to show that in the majority of cases in which Amenorrhœa is associated with insanity, the suppression of the menses is merely a symptom, and in no sense the cause of the disease.

In the “Journal of Mental Science” for April, 1883, I presented some statistics as to the recovery and death-rates of asylums, especially directed to the question of the effect of the size of the asylum upon them. In that communication I stated an opinion (p. 9) that the dominant element governing the different rates of recovery in different asylums was to be found in the different classes of cases admitted into different asylums, and expressed a hope of some day being able to make a further research in this direction. Table VII. of the tables of the Association obviously afforded the most hopeful available means of doing so, but how much could not be seen until a laborious abstract of its contents for a number of asylums over a series of years was made.

In none of the more practical aspects of insanity, with the exception perhaps of that of pathology, does the alienist stand at so much disadvantage with the other members of the medical profession as in the matter of prognosis. In diagnosis we have, as a rule, an easy task, though now and then cases arise in which it requires much thought to come to a determination whether some unhappy event is due to insanity or to crime. Again, in treatment we fairly hold our own, taking into consideration the complex nature of the organs and functions that are affected, coupled with the impossibility of direct examination and treatment of them. But in prognosis we are distinctly less sure of our footing, and it is unfortunate that this uncertainty is accompanied by a most pressing demand for accurate forecasts from the relatives of those who are placed under our charge. This pressure, no doubt, arises in chief from the necessity in nearly every case for modifying, either temporarily or for good, those circumstances, domestic, official, and pecuniary, from which the patient has been removed; but there is this further difficulty, that while in cases of general disease, other than insanity, the friends have some sort of knowledge and opinion of their own as to the probable result, gained from insight into similar cases, in insanity such clinical experience is denied them by the necessity for withdrawing patients from the observation of the public. They are thus almost entirely without guides of their own, and in consequence they come to lean more heavily on the doctor. The strain and responsibility for error thus cast on us would be intolerable were there only the two eventualities of absolute recovery and absolute loss of mind; but, fortunately, there are many stages to fill up the huge gap between these two extremes, stages of partial recovery which allow of the restoration of the patient to various degrees of liberty and usefulness in the world. It is not too much to say that the problem of the future of the patient has to be faced never less often, generally more frequently, than that of treatment.

Following the estimation of the state of the blood comes naturally that of the state of the circulation; and for the purpose of the alienist the efficiency with which the peripheral circulation is carried on is the main thing to be determined. From his point of view it is of far less importance to discover an insufficiency of the mitral valve than to find a cold blue flabby hand or nose; for a damaged valve is consistent with an efficient supply of blood to the highest nervous centres; but if one part of the peripheral circulation is seen to be badly carried on, the inference is unavoidable that the circulation in other peripheral regions is similarly defective. The direct evidence of the condition of the cerebral circulation obtainable by the ophthalmoscope should not be neglected. Although the “heat of the head” is a matter of prime importance among the laity, and is commonly considered by physicians as of some value, yet, having regard to the fact that the whole of the face and scalp are supplied by branches of the external carotid artery, while the encephalon receives its blood mainly from the internal carotid, I was for some time doubtful whether much stress should be laid on this external temperature. I have, however, seen a case in which not only did the head sweat freely, but steam rose visibly for many consecutive hours from the scalp of a woman lying in a well-warmed ward, and without any fluid or medicament being applied to the head. In that case there was found after death the most excessive congestion of the whole cerebral substance.

At the last moment I have been asked to fill up a gap in the programme of to-day, and if my paper be short and uninteresting, I must crave your indulgence.

In reading a paper on rectal feeding and medication I am not desirous of unduly extolling that form of alimentation and treatment, or of substituting it for the more direct, usual and natural methods, where the latter are feasible and effective. Deprecating any misunderstanding on that point, I speak in the first place of the principal conditions in which rectal feeding may prove useful in asylum-practice. These I will speak of in groups of diseases, or of cases, loosely bound together, for the nonce, by the tie of suitability for the use of nutritive enemata.

My object in this paper is to elicit the opinions of asylum superintendents in regard to the use of some form of alcohol in the ordinary dietary of institutions for the insane, and to state at the same time what I already know in respect to this question, thanks to the very general replies I have received from medical superintendents to a troublesome circular which I recently issued. It was not without much hesitation that I sent round these queries, well aware as I am of the multitudinous duties already devolving upon the heads of asylums; but the importance of the subject induced me to overcome this reluctance, and I take the earliest opportunity of expressing my appreciation of the kindness of those gentlemen who have taken the trouble to fill up the circular. As to those who have not done so, I readily take the will for the deed.

During the last four years, as medical officer in an asylum sufficiently populous to offer a fairly wide field for study, but not too large to prevent each individual case from receiving its own share of investigation, no subject has attracted me more than the occurrence of delusions of exaltation and optimism in the Insanity of Chronic Alcoholism. And this mainly for two reasons, viz., the divergence of opinion of good authorities as to the frequency of the association of such ideas with this particular class of insanity, and the difficulty which not seldom attends the accurate recognition of their true character and import. If in this paper I can report the salient features of these cases, they may, perhaps, have an interest to others to whom they present no difficulties in diagnosis; and if the inferences that are drawn from them seem occasionally to deviate from those of writers of experience, it must be remembered that the cases are too few to admit of any but tentative statements, and that such will be put forward as suggestions and not as dogmas, though at the same time the accuracy of the facts and descriptions from which they are deduced can be guaranteed.

The term posture indicates the relative situation of the several members of the body with regard to each other, or the relative situation of the parts of the member. Now, the posture is the result of the last movement; the description of a posture is the description of the effect of the last movement of the part. Postures may be seen as the result of the action of any part of the muscular system. We may speak of the posture of the hand and upper extremity, the head and neck, the back, &c. Postures depend upon the resultant action of opposing muscles, the relative tone of the flexors and extensors, the adductors and abductors, &c. In the limbs the opposing muscles act upon the bones and move the joints. In the face the contending muscles dilate and contract the apertures for the eyes, mouth, and nose, and otherwise alter the features; hence alterations in these characters in the face may be called its postures. The movements of the eyes being due to antagonistic muscles, the various ocular positions may be similarly termed.

The older writers on Insanity including Pinel, and Esquirol, believed that functional disturbances of the higher nervous centres were the chief factors in producing mental disease. Whether this is the case or not, and whether functional disease of the brain may exist without appreciable change of structure, there can be no question that the quantity and quality of the blood circulating through the higher nervous centres affect their functions in an important manner.