Section I. Difficulties of the Subject.—I find that I have not made my opinions as to the nature of Post-Epileptic States clear to many of my medical brethren. I may plead in extenuation that, as the subject involves consideration of Psychology, the Anatomy and Physiology of the Nervous System, and Clinical Medicine, it is not easily presented in a simple way. It would be an absurdity to attempt to simplify it by ignoring its difficulties, and, before such an audience as this, it would be impertinent to deal with it in a popular way.∗ In the investigation of so large a subject, having the several very different aspects mentioned, we ought to take into very particular account many things which are, I think, commonly little regarded in connection with it, or which are passed over as being irrelevant to it. As I deal with post-epileptic states as they form part of the subject, Comparative Study of Insanities, I must consider the three topics recently mentioned; and, as one of my aims is to show that the same general principles apply to diseases of all parts of the nervous system, I shall frequently take cases of non-mental diseases for illustration.

The subject of boarding-out is not in any way a new one. In 1864 Dr. (now Sir Arthur) Mitchell described very fully the condition of the insane in private dwellings in Scotland, and while exposing the many abuses that then existed, showed also that, under proper regulation, domestic care for a certain class of lunatics possesses many advantages, and urged that in it there could be found one very suitable method of providing against the accumulation of chronic insane in asylums. Since that time the subject has always been more or less prominently receiving attention from those who are concerned in providing for the insane. Therefore I cannot hope now to lay before you any fresh facts in reference to it. My object is rather, in the short time at my command, to draw attention to some of the outstanding features of the system, in the hope of raising a discussion and eliciting the opinions of members regarding it, especially the opinions of our friends from the other side of the border and from Ireland, where the conditions influencing the provision made for the insane are somewhat different from ours, and where boarding-out has so far not been practised to the same extent as in Scotland.

Delusional insanity or monomania has long been looked upon as one of the chief forms or types of insanity, and it is so described in the leading works on the subject. It is doubtful, however, whether it would be considered by all to be a pathological entity apart from other forms of insanity; indeed, many consider it as simply a variety of mania, and in the returns to the Commissioners of Lunacy mania and monomania are classified under one head. So far, however, from these two affections being allied, I venture to consider them as fundamentally distinct, and having each a pathology of its own. To put the matter tersely, I would say that mania begins from the top, monomania from the bottom. This proposition, doubtless, requires some explanation. I have elsewhere given reasons for my belief that mania is an affection of the highest controlling and co-ordinating plexuses of the brain; that what indeed we know as mania is the manifestation of activity on the part of certain lower centres (the larger portion) of the brain, this over-activity being permitted by under-activity, or abeyance of function, on the part of the highest centres (or smaller portion) of the brain. This is what I mean by insanity commencing from the top.

In undertaking to introduce a discussion on this very large and important question, I am conscious of my inability to do it justice. No one can possibly cover the wide range of subjects comprised in it; and I am anxious rather to elicit the convictions of more experienced men than to obtrude my own crude and imperfect ideas. My purpose is, therefore, to state the case as briefly as possible, and to introduce questions for discussion in preference to merely ventilating my own ideas. In this way we may arrive at some common points of agreement and materially advance our knowledge of the subject. There can be no two opinions as to the advantage of bringing to a focus the collective experience and conclusions of the various sections of our profession interested in this field of research, and the present opportunity is a particularly good one. The title of the discussion embraces a great deal, and yet does not strictly include topics which might be considered relevant, particularly therapeutics. My aim at the outset will be to invite your special attention to a few questions only, and in order to make the most of our time and concentrate the discussion as much as possible I propose to take each division separately. The subject, viewed as a whole, is so far-reaching and practical as to possess uncommon interest, for it links together medicine and psychological medicine, it gives an open field of discussion to general medicine, obstetrics, and psychology, and it views insanity on its less speculative side, because the more materialistic functions are brought out in strong relief, and sometimes even overshadow the characters of mental disease.

The frequency with which I am consulted about both men and women in whom an engagement of marriage has been associated with marked mental disorder, has induced me to bring the subject before this meeting of the Psychological Branch of the British Medical Association, especially as the subject naturally falls into a place in the larger subject suggested by Dr. A. Campbell Clark's papers on the perversions of the sexual and reproductive functions.