In the observations which I am about to address to you, I purpose to set forth by illustrations the character and course of a form of mental derangement which has its special cause, certain characteristic features, and a definite course, almost invariably from bad to worse. I speak of that kind of insanity which is brought on by self-abuse. In doing this, however, I have another object in view; I am anxious to use my exposition in order to exemplify a new and practical classification of insanity which has been proposed and sketched out by Dr. Skae.

I have been frequently obliged to give expression to my views on asylums and their future organisation. These views are expressed in official documents and private letters, which have never been published. A few observations which I made cursorily at the Naturforscher-Versammlung, in Hanover (“Zeitschr. f. Psychiatrie, “XXII., p. 390), as an indication of my point of view, were much too briefly and aphoristically given not to be subject to misconception. I therefore propose to devote the following pages to a connected, though necessarily brief, explanation of what I believe to be necessary or advantageous in the immediate future arrangement of lunacy matters in Germany, and to indicate towards which side I lean in the undoubted crisis which the question of the public provision for the insane has now reached. I apprehend neither detriment nor danger in this crisis, which is merely the progress towards more complete organisation. To wish to ignore it would not improve the matter. The predetermined conclusion to see the only good and right possible in things as they now exist is a far greater hindrance to the discovery of truth. If science can present new points of view, if urgent wants are brought to light, which cannot be satisfied by the present means of publicly providing for the insane, the requirements must not, in such circumstances, be ignored or denied, but the means must be made to suit the necessities. It was in this way that things were treated when the present asylums were founded; and is it possible that at the present time no further advance can be made ? It is, however, to be remarked, as was said a few years ago by Damerow, who was for the most part an authority with the opponents of reform (“Zeit-schr. f. Psychiatrie, “XIX., 1862, p. 187), “There is nothing further to be obtained in the future with the present public institutions for the cure and care of the insane.”

Among the structural changes which may cause the phenomena observed in insanity, physiology leads us to the conclusion that they must be connected with, firstly, the nerve tissues, and, secondly, the blood. It teaches us that upon the action that takes place between these elements the phenomena of mind depend.

Medical Psychologists have long been familiar with a peculiar form of disease which is characterised by a combination of disorders of the intellectual and motor faculties. The French physicians, to whom is due the honour of having first minutely described it, have given to it various names, according to the views then generally held and the special opinions of the individual observers: General incomplete paralysis (Delaye); general paralysis of the insane (Calmeil); general progressive paralysis (Requin, Sandras); paralytic insanity (Parchappe), &c. In Germany the terms general paralysis, paralysis of the insane, and most recently paralytic dementia have been generally employed. Familiar though this disease has become to medical psychologists, and though much discussion has taken place regarding it, within a narrow sphere, still slight has been the interest hitherto taken in extending that sphere. These poor patients, whose treatment either cannot or can only with great difficulty be pursued in the ordinary relations of life, who from henceforth appear hopeless, are gladly handed over to physicians to the insane, and with the entrance of the patient into the asylum all interest in the disease ceases. The time is, I believe, at hand when in regard to this, as well as to many other matters, the veil of the asylum will be removed, when once for all the barriers will be thrown down which divide mental pathology, as we must still call it, from that of the remainder of the nervous system. Each has a series of facts to oppose to the other, and it is certainly surprising how many points of connection there are between them. The question is merely one of comprehension: mental pathology often manifests itself in a manner which outwardly is not easily understood, though it must be admitted sufficient pains have not always been taken to understand these manifestations.

Man is born with a nervous system of the highest type, and in accordance with what we know concerning the laws of hereditary transmission, with one which—though at the time of birth so far advanced morphologically as clearly to foreshadow its future excellence—we are entitled to believe possesses within itself certain potentialities of organic development, definite enough and powerful enough to ensure its evolution in given directions, so long as its different parts are acted upon by those stimuli to which they have been accustomed in the preceding individuals of the parent race. To a certain extent the infant is even born already possessing capabilities of receiving impressions and of executing movements—corresponding parts of its nervous system being more advanced than others in histological development. And it may be stated generally, that these capabilities and these powers are gradually strengthened and extended in a definite order, as particular parts of the nervous system advance towards a more perfect development of tissue—that is to say, as nerve-cells and communicating nerve-fibres gradually arise out of the less specialised embryonic tissue which formerly occupied their place.

What asylum physician is there, who, in prescribing drugs for his patients, has any approach to a feeling of certainty that these drugs will have the effect he anticipates? I refer more particularly to sedative drugs. Is there any such physician who will lay down a rule by which it may be known whether opium, hyoscyamus, Indian hemp, or bromide of potassium is the best medicine to be given in a particular case? We have the statements of individual authors in regard to the right mode of giving some of these drugs, but after all those are merely opinions founded on most limited observations, and lack the exactitude of research, and the numerical basis on which alone scientific truth is founded. It is no wonder that many of our specialty are sceptics in regard to medical treatment in insanity, when we generally find that the advocates of particular medicines, or of special modes of administering them, merely give us “selected” cases. To anyone who has read something of the history of medicine, it seems a mere waste of words to advocate any new treatment of a disease, except it is clearly shown that the spirit of fairness and scientific impartiality has regulated the observations on which the would-be conclusions are founded. And as for discussing and quarrelling over the general question of the good effects of medical treatment versus moral treatment, surely the energy and acuteness so expended would be employed to far more purpose in observing and recording facts, so that we might have something certain on which to base an argument on the one side or the other. And by observing facts, I do not mean vaguely noticing the course of certain random cases subjected to unsystematic and desultory treatment, and accepting the confused impression of the result left on the mind as scientific truth, on which an argument may be founded or a boon to humanity conferred. It is surely possible for the physicians of asylums to combine their opportunities for observing the treatment of disease in one vast and systematic effort, all working on the same plans, and all adopting the same conditions. What accuracy might we not acquire in our notions as to the effects of morphia given in melancholia, if the drug was tried in the case of every melancholic patient in all our asylums for a year, and an accurate record of the results drawn up? The idea may seem in many respects chimerical and absurd, but it seems questionable if much accuracy in therapeutics will ever be attained until something of the kind is done. There is no single man who has opportunity sufficient to solve such a problem, except by careful experiments extending over years, and we know how difficult it is for a physician to continue careful experiments over long periods. And surely this exact, scientific, and statistical age will not allow the present state of utter doubt to continue much longer without making at least an effort to dispel it. We require to know the full and true result of giving drugs in every case, and not merely in a few favourable cases which may be natural recoveries.

When I was engaged a short time ago in trying to determine accurately the effects of certain medicines on maniacal and epileptic patients, the temperature of the body in those patients was one of the things noted by me; and being unable to find in any book the normal standard in the insane, I made and analysed 2000 observations of temperature, so that I might have a standard with which to compare my cases. I examined and noted the temperature of all the patients in this asylum, using the thermometer recommended by Dr. Aitken. I took the temperature in the axilla, and my object being a practical one, instead of examining the patients at the times when the maximum and minimum heat is usually found, viz., immediately after waking, and at midnight, I did so between ten and 12 o'clock in the morning, and between nine and ten o'clock at night. The patients here all get up at 6.15 a.m., and go to bed at 8 p.m. Perhaps those hours will, on the whole, be found more useful and convenient than welfare of the patients are being seriously compromised—before the most congenial treatment for a whole class of patients is established. No. This system should be recognised at once in the first plan of every new asylum as necessary, essential, and immediately required.

From the brief summary I have given of the labours of the pathologists of the French school, it will be observed that the evidence deducible therefrom is of such a conflicting character as to leave quite unsettled the complex question of the localisation of the faculty of speech. The history of the continental contributions to the literature of aphasia would, however, be very incomplete, without a brief glance at the researches of the German and Dutch physiologists.

Shakespeare has used the character of “Achilles” to pourtray in vivid language his own conception of a malady of the mind which modern pathologists choosing to consider have made familiar to us under the term of “General Paralysis.” Doubtless, the recognition of this as a distinct phase of insanity necessitating confinement in an asylum dates from comparatively recent times, but Shakespeare not only remarked and described the chief symptoms, but also noted them as constituting a disease of the mind, though probably he would not have classed those so afflicted with the rest of “Bedlam Beggars.”.

Perception we define to be the intellectual and presentative consciousness of objects of any kind, internal or external, and the primary gateway of knowledge. In every perception the object is a most prominent feature. It is in the invariable presence of the object in perception, and its absence from memory and imagination, that we behold the striking difference which there is between it and the latter; and it is on this distinction the universal assurance is grounded that what we perceive is different from what we remember or imagine. In every perception there is an intellectual and a sensational element, and memory proper is the persistence of the intellectual element after the sensational element has disappeared from consciousness, or after the peripheral nerves have ceased to excite the sense-centre. In no instance have we been able, by any amount of effort, to make an act of memory or imagination seem a perception; yet Hume divided perceptions into two classes, as distinguished by their different degrees of force and vivacity. The less lively he named thoughts and ideas; the more lively, impressions. Professor Bain seems to take the same view of the question. In reference to the recalling of past feelings, he says:—“The renewed feeling occupies the very same parts, and in the same manner, as the original feeling, and no other parts, nor in any other manner that can be assigned.” It is the opinion of some, then, that memory and imagination only differ from perception in being less lively. The latter is a vivid picture, the former are faint reproductions of it. We fail to see that this is precisely the case. In every perception there is an object present, and cognized as distinct from the consciousness of it—in special instances, as even distinct from the perceiver altogether. When we gaze at a picture, the picture is regarded as one thing, the knowing of it as another; whereas when we only think of the picture, we do not recognize any object as really distinct from thought itself. An imagined external object is still detected to be a mental object. “A representation considered as an object is logically, not really, different from a representation considered as an act. Here object and act are merely the same indivisible mode of mind viewed in two different relations… The same may be said of image and imagination.” “Imagination, regarded as a product, may be defined, the consciousness of an image in the mind resembling and representing an object of intuition.” Though we do not exactly hold with these opinions, we quote them in order to show what view is taken by some psychologists in reference to the distinction between presentative and representative consciousness, or between knowing a thing immediately in perception, and knowing it mediately through an image of the mind's collecting. How is it possible, when contemplating a mountain which one is on the point of ascending—albeit the mountain is to us, as immediately known, in a sense-centre—to regard it as identical, except in vivacity, with the recollection which we afterwards have of it? Perception is, so to speak, a bi-une fact, a synthesis of cognition and object, whereas memory and imagination are not bi-une, for the object is not present in them, in the same manner, at least, as it is in perception. But let us now proceed to adduce facts and deductions confirmatory of this view of the question.

The Hospital de los Locos at Granada is the oldest lunatic asylum in Europe, having been founded by Ferdinand and Isabella shortly after the conquest in 1492. It was therefore opened some fifty years before the first Bethlehem Hospital, which stood in the present Bethlem Court, off Bishopsgate Street. It has apparently been carried on these two hundred and fifty years without any alteration in the original structure or any advance on the method of the original treatment. I induced to visit it last April, from a notice of it in Ford's Handbook. “At the corner of the Plaza del Triunfo (he writes) is the Hospital de los Locos, founded by Ferdinand and Isabella, and one of the earliest of all lunatic asylums. It is built in the transition style, from the Gothic to the Picturesque, having been finished by Charles V. The initials and badges of all parties are blended. Observe the patio and light lofty pillars. The filth and want of management of the interior is scandalous, and yet this is one of the lions which Granadians almost force an Englishman to visit; possibly from thinking all of us Locos, they imagine that the stranger will be quite at home among the inmates.” The asylum is a two storey square building, with enclosed courts, which form the patients' airing courts. They are of small extent, and excluded from all view by the buildings, which, however, shade from the sun. In one of the courts I noticed a large summer house, over which a vine was trained. The dormitories contained twenty-five beds each, and were large and well ventilated. Single rooms opened off them, with rather unpleasant arrangements (to English ideas) for night stools; but then all these arrangements in the best hotels in Spain are nasty to a degree, and at the railway stations, if possible, worse. What a boon the earth closet system would confer on travellers in Spain! The patients, about 250 in number, were on the whole quiet and orderly in their conduct, and fairly clothed and tolerably clean, when contrasted with the population at large. So quiet was the whole system that I did not hear one sound in all my visit, but then the Spanish people are a quiet, phlegmatic race, patient of suffering, and who stupify themselves with the constant and excessive use of tobacco. I saw one man in permanent restraint, with formidable leg locks and chains, but he could walk freely, and had the use of his arms. There was, I was told, no straight jacket in use at the time of my visit, but I was shewn a strong implement of the sort, with a lot of leather and straps about it, and which was said to be frequently required.

That medico-mental science is often at variance with the doctrines and decisions of the courts of law is a fact too well known and too generally admitted to need formal proof. It is almost as generally assumed that the scandalous failures of justice, which too often result, must be attributed to the defective education and knowledge of the profession. It is alleged that, as a body, we are for the most part ignorant and theoretical in matters relating to insanity, and if not ignorant, then presuming, and often using the little knowledge we possess, rather with the intent to rescue thieves and murderers from the legal consequences of their crimes than to help the administration of justice. It is certainly a fact which many of us lament that the corporate bodies of the profession generally, including the general medical council, ignore the subject as a distinct department of medical education; and consequently medical practitioners, not being duly trained, do sometimes appear to great disadvantage in courts of law. Medical shortcomings are not, however, the subject of my paper, but certain fundamental defects in the principles and procedures of the law which render medico-mental science sometimes even worse than useless, and always less useful to the commonweal than it might be, if rightly adapted to the needs of modern society. Nor would it be difficult to show that some of the crime and folly which occupies our courts and fills our reformatories, prisons, workhouses, and lunatic asylums, is capable of prevention by a well-devised use of medico-mental science. As these matters are wholly beyond the powers of the profession, I shall ask leave to move at the close of the discussion that a committee be appointed, with power to take such steps as may be thought necessary to secure a thorough inquiry by the Government into the relations of medical science to the administration of the law in regard to all persons mentally disordered or defective, with a view to such improvements as may be practicable.

In the dominion of Canada and the adjacent provinces, embracing a population of three and a half millions, there are eleven asylums and hospitals for the insane. The smallest of these accommodates forty patients—the largest, six hundred. Their character, as curative institutions, varies equally with their capacity. The annual reports of the greater number present very satisfactory returns as to the proportion of recoveries, the rate of mortality, and their economical administration. No one institution will be found to excel on all these points, but the statistics of those best managed will compare favourably with those of the leading asylums of Britain or America.

The constitution of man is tripartite; his well-being depends upon the soundness of his physical, mental, and moral condition. These three conditions are quite distinct, though they do not exist separately; a combination of them all in their different degrees and relations is necessary to the right exercise of their respective functions. They are all material, that is, they are essential conditions of the structures which represent them, and on the integrity of which their existence depends. There may be some hesitation in admitting this statement as regards the moral qualities, at the same time there is a wide difference between the feelings and passions which man possesses as a creature, and the principles of justice, mercy, and truth which are the attributes of the Creator. Mere feelings and passions belong to animals as well as to man. It is the association of these with the higher principles of which man's nature is capable that constitutes the emotions. The distinction between his moral qualities and the higher principles with which man has been endowed in order to guide them is, that the former move him in so much as they affect his physical condition, the latter simply raise and elevate his whole character. Thus, the passion of anger may excite a man and flush his face, disappointment may depress him, and fear blanch his features, but the exercise of justice, mercy, and truth do not disturb him; in proportion as he possesses these qualities he rises above his natural condition, and in proportion as he is deficient in them is his tendency to become degraded.

Having in the preceding pages endeavoured critically to review the question of the localisation of the faculty of speech, as illustrated by the labours of the French, Dutch, and German pathologists, as well as by those of the different branches of the Anglo-Saxon race, I now proceed to place on record a certain number of cases which have been observed by myself, and in several of which the clinical history was completed by a careful post-mortem examination.