Seven years ago Dr. Clouston read a paper to this Association “On the Question of Getting, Training, and Retaining the Services of Good Asylum Attendants.” Such a paper could scarcely fail to attract considerable notice and elicit a very hearty discussion, for the subject is one of far-reaching importance to us as asylum physicians, and of very great moment in the interest of the insane. To get the best raw material possible, and to manufacture out of it the best asylum attendant possible, were two great aims suggested by Dr. Clouston, and the subsequent discussion of his paper showed that the Association was fully alive to these, and the serious obstacles which lay in the way of their accomplishment. If the aims here indicated should be more fully realised in the future than in the past, we will probably find that the third desideratum, viz., the keeping of our attendants for a reasonable length of time, will be realised in like proportion as the others. We all willingly admit that the first serious difficulty is how and where to get them. What will attract the best raw material into the asylum market ? or, putting the question in a negative way, what is it that does not attract the best raw material into asylums? These questions will admit of a variety of answers, many having their root in the idea of non-respectability. Undoubtedly the status of an attendant is at present an inferior one in the industrial scale. Some common popular notions are that the rougher and stronger the material the better is the attendant; that it is not a trade for men, and is suited only for the coarser types of women; that it leads to nothing reliable or desirable as a permanent occupation; and that as a life-work it is not sufficiently respectable to satisfy an average ambition. These and other considerations materially affect the supply of good attendants. Seeing, therefore, that in attendants themselves we find the best advertisement, and through them may command the highest success, it is worth considering, whether or not it is possible for us to advertise asylums, in such a way as to attract to them the better raw material which we crave so much after, and which we need so much. If the public mind must be educated to better purpose we must go upon a new tack. We shall require to bring more elevating influences to bear upon our attendants. In raising their social and industrial status we shall raise them in the estimation of the public and themselves, and may reasonably expect a more marketable article by-and-bye. It is surely fair, in the interest of all concerned, that attendants should receive from us the best possible training of which they are capable. There is reason enough for it in this, that as medical helps they will then develope more fully, and their work will become a life-work worthy of the name.

In support of the position that small asylums are, even from an economic point of view, better than very large ones, Dr. Hack Tuke, in his recent work on the “History of the Insane,” cites the opinions of the Lunacy Commissioners, as given in their Report for 1857. He also gives in the appendix some figures which the Commissioners prepared in regard to the weekly cost of patients in large and small asylums, and which were adduced by them to support the same view. He found, however, that on taking an average of the six largest and six smallest asylums in the list, the weekly expenses per head in the latter appeared to be really greater than in the former—a result different from that for which he had cited them from the Blue-book.

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.

I have been incited by Dr. Rayner's paper in the “Lancet” of Dec. 80, 1882, to look up various old calculations of mine, bearing on the relation of size of asylums to efficiency and economy, and think it may be worth while to throw them together, that any lesson they may contain may be elicited. I find I have various tables of the relation of cost of maintenance in asylums to their size, and also several relating to the relative rates of recoveries and deaths in asylums of different sizes.

Since a knowledge of the Physiology of Mind is essential to a clear comprehension of its Pathology, we may fitly introduce a paper purporting to deal with one form of abnormal mental action, with a few considerations concerning mental action in general.

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 question of the legal responsibility of the insane has been frequently under discussion both by legal and medical writers; and its conditions and limits must, I fear, still be regarded as far from settled; divergent views being held, perhaps naturally, according to the standpoint respectively taken up by the lawyer and the physician. “A lawyer, when speaking of insanity,” says Sir J. F. Stephen, “means conduct of a certain character; a physician means a certain disease, one of the effects of which is to produce such conduct.” It is somewhat remarkable that the legal responsibility of the idiot, and of his milder congener, the imbecile, has hitherto hardly been deemed worthy of discussion; but a recent law case, in which several patients under my care were concerned, has led me to think that a few remarks on the subject may not be altogether uninteresting or unprofitable.

Joan's glory reached its highest point when she led the Dauphin to be crowned at Rheims. Up to this time every thing had gone on as she desired, and as she had predicted. The caution of experienced generals had again and again been overruled by her impetuous call for action. One blow after another had been struck, and every blow told. Fortifications, apparently too strong for the force brought against them, had been stormed; seven cities had been taken; and at Patay an English army had been scattered and slaughtered like a herd of deer. The newly-crowned King was urged unwillingly to St. Denis, and a furious assault made upon Paris from noon to sunset.

An old teacher of mine, in days gone by, used frequently to remark in his lectures on Logic that the test of accurate knowledge is the ability to give an exact and comprehensive definition. Now, if this criterion were applied to us, alienists, in regard to the subject we are supposed to know most about, the result would, I fear, be somewhat disastrous, and not at all likely to shed lustre on our speciality.

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. †

At the annual meeting for 1880, one of the Editors of our Journal asked the members present for contributions on the subject of practical details in asylum management, pointed out the value of improvements in such directions, and expressed the opinion that such topics came most properly within the scope of a good asylum physician.

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

In investigating the complicated phenomena of mental action, normal and abnormal, it is not sufficient that we confine our attention to the nervous system in its latest stage of development, but we must direct our thoughts to the manner in which it has been built up; in other words, if we wish to understand how the nervous system acts, we must see how it has been developed.

Is Miliary Sclerosis a fore-death change? Most of us have believed it so: many of us doubt, myself amongst the many. As to the grounds of my unbelief, they are briefly these:—

The study of the Laws of Heredity, as conducted in the preceding papers, has resulted in a definite conclusion, it is true, but in a conclusion as to tendencies only; and whatever facts we may ascertain in the family history of a patient, however numerous and however damning they may be, they can never warrant us in inferring anything whatever with respect to that patient, beyond the existence of a tendency in one direction or another. To ascertain how far, and in what proportion, these tendencies, in so far as they concern the Structure of the Organism, have become actualities, recourse must be had to the study of the Physique, which is the outcome of the combinations, and conflicts of the laws of inheritance. Or, in other words, the Physique is the form which the organism has assumed under the action of the developmental forces.

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 has been stated by some that it is syphilis originally mild and benign in its manifestations, that is most apt to cause cerebral syphilis; one saying that the subjects most liable to cerebral syphilis are those in whom the secondary symptoms have been slight or transitory; another asserting that often one can find no history of preceding cutaneous or other affection of either the secondary or tertiary order; another, that any syphilis may be followed by specific cerebral affections, the original mildness of a syphilis being no guarantee against future cerebral affections of syphilitic origin, and that the great majority of the cerebral affections are furnished in examples of syphilis which is of medium severity, or (less often) is benign. This last observer, in 47 cases of cerebral syphilis, found three after severe or grave syphilis; 30 after syphilis of medium severity, and 14 after syphilis benign in its manifestations. As stated by myself in a paper published more than seven years ago: “It is particularly in instances where syphilis affects the nervous system that its evolution is sometimes insidious; that its later lesions are not preceded by its usual characteristic development on the exterior of the body, or by only a partial, or slight, or transitory development; and that the diagnosis is surrounded by obscurity. This is the opinion of several writers on the subject, and more than once the fact has forced itself upon my attention.”