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.

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.

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.

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.

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.

We propose in this paper to deal with the subject of the effects produced upon mental disorders by intercurrent bodily disease. The theme is an old one, but we feel justified in calling attention to it afresh, partly because it is at present prominently before the minds of many alienists, partly since those who have concerned themselves with it—in this country, at any rate—have principally been content with the mere indication of the facts observed. The pathology of the subject, the domain of experimental research and scientific speculation, remains comparatively unexplored. Our literary survey leads us to conclude that but little has been written upon this subject of late years.

Whilst studying the pathological changes met with among those dying insane, I was much struck by the large number of cases in which chronic renal disease of a more or less advanced state was present. This led me to work out, from the post-mortem records of the Somerset and Bath Asylum, the percentage of chronic renal disease noted in such cases. But whilst engaged in these inquiries my attention was especially called to the number of general paralytics presenting this condition, and I proceeded, therefore, to collect all the cases of general paralysis of which the records were sufficiently trustworthy. In this way I collected 75 cases, and of these only nine were free, or apparently free, from renal disease. Of the 66 cases remaining 51 had what must be considered well-marked granular kidneys, and the other 15 had diseased kidneys which were most probably granular, though in a less advanced degree. One of these latter cases had renal calculus. In other words, only in 12 per cent. of the cases were the kidneys apparently healthy, and we may, I think, take it that almost all the remainder (88 per cent.) had granular disease of the kidney. I do not suggest that this is the usual percentage, but among the cases of one asylum it is sufficiently remarkable.

In the spring of 1893 we received from Dr. Mercier an instrument specially devised by that gentleman for the purpose of automatically registering the breaking strain of the human rib. It was accompanied by a letter, in which we were requested to experiment with the instrument on as many cases as possible and furnish him with the result. By that letter we were at the same time informed that he had sent similar instruments round to other asylums with a like supplication, and that he looked for the co-operation of a number of colleagues in enabling him to collect a number of cases sufficient to constitute a foundation for an accurate statistical record—a record which would, among other things, settle once and for all in which varieties of mental disorder it is that we are to look for ribs possessing a low breaking strain.

Passing to the treatment of special classes of patients, Professor Meyer expresses decided opinions, which seem to be somewhat in advance of the general consensus. For instance, at Alt Scherbitz, or in the remoter asylum of Bayreuth, one finds a considerable amount of restraint and special arrangements for the destructive and violent. It is, therefore, necessary to accept certain statements under the following heads as being more personal than representative.