The new position in which you have done me the honour this day to place me, entails upon me the duty of passing in review the varied interests and difficult problems of social and medical science, which are necessarily involved in promoting that which is the primary object of this Association, the welfare of the insane. The welfare of the insane! What a world of interests does not this small phrase include; what questions of individual happiness or misery; what questions of the prosperity or ruin of families; what questions of morality and law, of religion and politics; in fine, does it not ‘inferentially include the welfare of the human race. From time when Nebuchadnezzar ate grass, the happiness of the human race has often been at the mercy of the not metaphorical insanity of its rulers; and how often does not madness in lower stations imperil all that is precious. A mad orator on the floor of the house, or in the pulpit, may do comparatively little mischief, for opinion breaks no bones; but madness in a man of action, in an admiral for instance who commits suicide in the heat of an engagement, or an engineer in charge of a railway train; to what fearful disasters may it not give rise? In the world there is nothing great but man, in man there is nothing great but mind, says Hamilton. How vast, how wonderful a subject of study, therefore, is mind, whether in its integrity, or its decadence and ruin, in its health or its disease! Mental physicians, are we pledged to devote ourselves to the contemplation, and, as far as may be, to the full appreciation of this great subject, that we may oppose decay, and relieve disease ? Would it were possible to prevent it! Mental hygiene is, indeed, a subject vast as that of human progress. The highest and lowest stages of human development, those of the savage and the practical philosopher, are, perhaps, almost equally free from this direst scourge of human pride; the one with passions undeveloped, the other with passions under subjection. But the line of progress from one to the other of these termini, is strewn with those who have fallen in their weakness to linger and to die. Madness, the Nemesis of that ill-directed, ill-regulated development that we call civilization, what if it were to increase until the tendencies to mental disease overweighed in the community the conservative powers of health! There have been communities and times in which physical disease has threatened, or actually put an end to a race of men; and there have been communities and times in which folly and passion and delusion have been so widely endemic, that the fabric of society has been torn down, and even its very foundations shaken; and were it not for the resiliency of nature, the benign law of adjustment, by which deviations from law are a check upon further deviation, it is possible to conceive that the tendencies to mental infirmity and disease should increase; that passionate selfishness and insane folly should have continually augmenting power to reproduce themselves until acquired, and hereditary tendencies to madness should overbalance the forces of self-control and sanity, so that an observer, neither cynical nor metaphorical, might justly exclaim upon the “mad world,” and races, like families, become impotent for all except mischief and disaster, until time, the great physician, brought the only cure in extinction. Such speculations as these are not without their use, impossible as their realization may appear; they at least serve to make us value rightly the blessings we enjoy, blessings which from their commonness we are too apt to over look. We have no earthquakes in this country, and we calculate upon the stability of our buildings; we have no dead calms, and that world without motion, whose stagnant putridity has been painted by Byron and Coleridge, is to us a dread but impossible imagining. But the stability of our dwelling-place, and the restless agitation of the elements, although among those simple elementary conditions upon which our being depends, are also conditions which it is most easy to conceive might have been otherwise.

The Chair was taken by Sir Charles Hastings, d.c.l. The following members, among many others, were present:

The case, to which the observations I am about to make refer, is not, I think, without some interest to us, both as medical men and a? the proprietors or superintendents of private or public asylums. It is calculated, as I believe, to illustrate the not very enviable position we may be, under circumstances, placed in, in reference not only to the Commissioners in Lunacy, but to the public; whose servants the proprietors and superintendents of asylums, of all kinds, are to be considered. The case, moreover, follows, and very properly, the paper of Dr. Conolly's, entitled “On the Prospects of Physicians practising,” in our specialty.

The regions of religion and philosophy are distinct, but by no means opposed. Some professors of the Christian faith may have fallen into the error that revelation and science are antagonistic, but such a position has neither any foundation in fact, nor any countenance in the Divine record. Warnings, no doubt, occur in the apostolic writings under the head of science and philosophy; but these are directed against “science falsely so called“, and such philosophy as is identified with “vain deceit.” There can be no opposition between nature and revelation, inasmuch as the author of both is the same God, who is “light“, and whose essence is “truth”. In examining therefore a mental phenomenon, such as that of Revivalism, as lately exhibited in the northern counties of Ireland, and during whose rise and progress so much of a religious element was developed, it would be, in a manner, impossible to do justice to the subject, without a direct reference to this element; nor will the interests of evangelical truth be injured, by an endeavour to discriminate between the false and the true, the genuine and the factitious, in this singular excitement; neither, I must presume, will the pages of a journal devoted mainly to subjects of a psychological character be diverted from their legitimate application if the Religious Aspect of Ulster Revivalism be introduced to them.

The liberty of the subject, so dear to all Englishmen, is under certain conditions placed by the law of the land at the discretion of any two qualified medical men. That the confidence thus reposed in the members of our profession has not been abused is proved by the evidence of an unimpeachable witness, namely, that of the Earl of Shaftesbury, who, as Chairman of the Commissioners in Lunacy, asserted before the special Parliamentary Committee, that in his experience of nearly thirty years “there has not been more than one or two cases in which any person has been shut up (that is, in a lunatic asylum) without some plausible ground for his or her temporary confinement; but in every instance, with these exceptions, there have been certain plausible grounds in fact or in logic, sufficient to justify the temporary confinement of the persons, and their being submitted to medical treatment.” It is highly creditable to our profession, that a man of Lord Shaftesbury's position and experience should be able to give this strong and definite testimony, to the manner in which the statutory powers of medical men in giving certificates of insanity have been exercised; but at the present time it is not my desire to dwell upon the sound judgment and honest intention with which this great social responsibility has been discharged, but to direct the attention of the meeting to the abundant and constantly recurring errors of form, which are committed in filling up medical certificates, in the hope of affording such few hints as my experience may suggest, by which they may be avoided. So abundant are these errors, that I hear medical gentlemen connected with private Lunatic Asylums assert that it is the exception, and not the rule, to receive with a patient, admission-papers which require no amendment. Indeed, a physician in charge of a first rate private asylum assures me, that he has never yet received admission-papers which did not need amendment. This is a matter of great importance, for (to say nothing of the delay and expense incurred in procuring these amendments, which are so great that the proprietor of a large private asylum assures me, that he invariably prefers the expense of procuring altogether new certificates) any errors or omissions, not discovered and rectified, would leave the proprietor of an asylum liable to heavy damages, under an action for false imprisonment. The courts of law very properly require that these medical documents, under which men are deprived of their liberty, shall be drawn up in exact accordance with the provisions of the statute. An early illustration of this principle was afforded by the decision of Mr. Justice Coleridge, in the case of Mr. Greenwood, in which he declared that the medical certificates were invalid, and that the patient had been improperly confined, because the name of the street, and the number of the house, in which the medical examination had taken place, were not stated upon the certificate. The formal part of the certificate is indeed a very simple one, and contains no one thing which might be omitted.

It still, I think, unnecessarily remains a disputed question, whether the mental affection in general paralysis does, or does not, precede the symptoms that mark enfeebled muscular power. Esquirol, indeed, distinctly states, in speaking of the corporeal paralysis, tantôt elle précède le délire, but it must be clear that this is after all negative testimony, it only means that Esquirol has been told so; it can only go to prove, as a close examination of the case quoted by Calmeil proves, that there were no symptoms observed by the friends of the patient, to lead them to suspect insanity, before the paralysis appeared. It has always been taught by Dr. Conolly, that the mental symptoms are synchronous with, or antecedent to the paralysis, and this is consistent with Esquirol's conclusion, that general paralysis is a “complication of insanity“; a definition called out by the not very lucid objection of Dr. Burrows, that he, Esquirol, seemed to think the paralysis to be the “effect, and not the cause of the insanity.” The real question to be decided is, whether in an undoubted case of ‘general paralysis,’ with mental aberration, the paralysie générale of Calmeil, there has ever been a period of the malady during which, with the muscular affection distinct, the mental powers were unaffected ? I have never seen such a case, and with my strong opinion of the special nature of the disease, should not expect to do so; it has already been pointed out that the statement of the paralysis existing with ‘weakening of the intellect,’ only widens the question into a consideration, of how small an amount of weakening constitutes unsoundness of mind. The existence of a case ultimately becoming insane, presenting paralytic symptoms, and yet showing undiminished mental vigour for some time after they appeared, if recorded by a competent observer, would go far to shake the opinion held by many of our leading physicians, as well as by myself, that general paralysis is a disorder, sui generis, and, though neither ‘cause or effect’ of unsoundness of mind, inseparably connected with it. At present, no such case is on record.

It is only after much thinking, and with much hesitation, that I venture to advocate in the following pages, principles as to the size and construction of lunatic asylums, which I believe to be at variance with those upheld by the highest authorities on this subject; but the question how provision may be best made for the enormous number of lunatics now known to exist in every civilized country, is one of such importance, and still so far from having received a satisfactory answer, that it seems a matter of duty on the part of every one who has had favourable opportunities for considering the matter, to place his views before the public. In this, as in other questions, full and free discussion seems to offer the best chance for a speedy arrival at the truth, and though my views may not meet public approval, yet their publication may contribute to enquiry, and thus tend to a satisfactory solution of the question. I am of opinion, that asylums of large size are the best adapted for the curative and humane treatment of the insane, and whilst I am not prepared to say what limit should be put to the size of an asylum, I do not consider that Colney Hatch, which is the largest of our public asylums, would be too large, if its internal construction had been arranged so as to meet certain modifications in the principles of management, which, in my mind, would be advisable in all asylums, but which are still more requisite in those of large than of small size.