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shown that a disease indistinguishable from it, and this evenas regards its paralytic sequelro, was known before theChristian era, and as to this country the quaint writings ofNoah Webster were quoted in which comets, meteors, andother phenomena were conjured up to account for epidemicsof throat disease other than acarlatina,, which vividly re-

called the several features of diphtheria prevalences in ourown day. The first recognised prevalence of diphtheria inEngland, alleged to have been imported from Boulogne, wasdiscussed in connexion with the writings of Simon, Green-how, and Bardon Sanderson ; and then the general distri-bution of the disease in different parts of England andWales was considered in some detail by the aid, in theanain, of Dr. Longstaff’s statistics. The broad geologicalfeatures of the country were shown to have no direct influ-ence on diphtheria mortality, and as to attacks apart from- death no sufficient data are available. Some areas

in the same geological formations exhibited the most

striking contrasts in this respect; but at the sametime Dr. Thorne differed from other authorities who(had declared that soil, and this even when altitude.and dampness were also in question, had no concern in thedevelopment or diffusion of the disease. The two areas inour own country where diphtheria had caused the highestrates of mortality were shown to lie along our exposedmorth-eastern and eastern coasts, and in the mountainous,districts of Wales, and this especially in the damp valleys!so abundant in some Welsh counties. Clays, as such, were;shown not to have excess of diphtheria death ; indeed, thegreat stretch of the Oolite from the borders of Lincolnshireinto Dorset, where clays abound, was the line of England’sgreatest immunity from diphtheria, a circumstance whichvas largely attributed to the facilities for drainage affordedby the flow of the great rivers which drain that area. Onthe other hand, where water was upheld in clays or in,gravels, and where to the resulting dampness was super-added a cold, bleak air and vegetable decomposition, thereit was held that conditions favourable to diphtheria existed.But at the same time other conditions favourable to the,disease were shown often to outweigh all considerations ofclimate and of soil. These points having been somewhatfully discussed by the aid of charts and diagrams, Dr.Thorne further illustrated them by somewhat detailed re-ferences to epidemics which he and his colleagues at theLocal Government Board and various local health officershad investigated. And as to the influence of soil-wetness,it was suggested that whilst stagnant water, like stagnantair, was conducive of ill-health and probably of diphtheria,the result of moving water, as in the drift along the beds of;great rivers, was probably in no such way injurious.The influence of season was next considered, and it

was shown generally that over a long period of years’excess of diphtheria mortality had occurred during thefourth quarter of the year, a circumstance that had in’some respects been held to favour the view of a fungoidorigin of the disease. Comparison between attacks and,deaths from this disease was not possible in the case ofthe large towns where compulsory notification had beenadopted, and the records as to this, which had been com-piled owing to the initiative of Dr. John Tatham, werereferred to in this connexion, with the result of showing=that a striking rise in diphtheria mortality takes place inthe month ot October, that this hardly abates during:November, but that after this it shows a tendency to,diminish. But with regard to attacks it was evident thatdiphtheria increased at an earlier date, the month ofSeptember showing a marked number of attacks. And, onthe other hand, the January deaths from diphtheria were,in not unimportant amount, due to attacks commencing inDecember. How far these urban statistics could be heldas applicable to rural areas Dr. Thorne did not feel able to,say, but the urban experience was stated to be generally’the same as that observed in prevalences, that had beencarefully investigated in the country, as a whole.Coming next to the question of sex, some of Dr. Thorne’s

experiences were referred to, and this especially where hehad expressed the opinion that the excess of diphtheria in’females over males during the first fifteen years of life wasprobably due to the fact that female children are likely to bebrought into closer contact with the infected sick than isthe case with boys. This bad been generally accepted byDr. Downes as applicable to females who had passed theage of childhood, but the latter observer had broughtforward a number of statistical and other considerations

which he thought tended to show that there was also somephysiological proclivity amongst females to take the in-fection beyond that which attached to males. Dr. Thorne,on the other hand, gave his reasons for believing that ingirlhood, as in early womanhood, there was in femalesopportunity for greater and more sustained exposure toinfection than in males.The question of age incidence as a predisposing cause

was also fully discussed. The greatest proportion of totaldiphtheria deaths was shown to fall on the period three tofifteen years; a still greater incidence was found on theperiod three to twelve years, and a further excess on theperiod two to five years. The comparative scarcity ofdiphtheria mortality was referred as related to such cir-cumstances as avoidance of exposure to infection, the useof breast milk and of milk preparations practically sterilisedin process of manufacture, as possibly also to the rudi-

mentary character of the tonsils at a period of life asso-ciated with the functional obliteration of the thymusgland. But this question of age incidence was found tobe much involved in other considerations. Thus, the agethree to twelve years is essentially the school age, and so-called school influence here comes into operation ; it is theage when diphtheria is a much more recognisable diseasethan at some later ages, and in rightly appreciating howfar question of age may be one merely influencing theclinical features of the local affection, much was held todepend on the right interpretation which ought to be puton the term " diphtheria " as used both in mortality and insickness returns.

ABSTRACT OF THE ORATION OF THE HUN-TERIAN SOCIETY FOR 1891,

ON PSYCHOLOGICAL MEDICINE IN JOHNHUNTER’S TIME AND THE PROGRESS

IT HAS SINCE MADE.Delivered at the London Institution,

BY FLETCHER BEACH, M.B., F.R.C.P.,MEDICAL SUPERINTENDENT, DARENTH ASYLUM ; HONORARY

SECRETARY, MEDICO-PSYCHOLOGICAL ASSOCIATION.

MR. PRESIDENT AND GENTLEMEN,—When you did methe honour to request that I should undertake such an

important duty as the delivery of the Hunterian Oration, Ihad some difficulty at first in deciding upon what subject toaddress you. The life of Hunter has so frequently beendwelt upon by brilliant orators, such as Paget and others,that it is impossible to bring before you any facts that arenot already perfectly well known. On reading an accountof his life, one cannot but be struck with his marvellouspower of work, his untiring energy, and his completedevotion to science in so many departments. Lawrencetruly said that " he was the greatest man in the combinedcharacter of physiologist and surgeon that the whole annalsof medicine can furnish." Physiology, surgery, and theformation of his museum did not take up the whole of histime, for, on looking through the first volume of his " Essaysand Observations," arranged and revised by Sir Richard0 wen, I was surprised to find that he was also a psychologist.Hunter was eminently a practical man, and, had he lived longenough, he would no doubt have applied his psychology to theelucidation of many points in surgery and medicine. Ittherefore occurred to me that the condition of psychologicalmedicine in Hunter’s time and its subsequent progress might.be a profitable subject whereon to discourse to you.

It appears that during the earlier years of Hunter’s lifethe belief that the insane were possessed of the devil hadnot entirely passed away, and ignorance and superstitionguided the treatment. Ducking the lunatic was practisedin some parts of Cornwall, while in Scotland lunacy healingwells and superstition survived as late as 1793. In Ireland

: the most important of the many stories connected with the: treatment of the insane is that concerning the Valley of the

Lunatics, in which are two wells, to which lunatics used toi resort, drink the waters, and eat the cresses growing oní the margin ; the firm belief being that the healing water,I the cresses, and the mysterious virtue of the glen would

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effectually letore the madman to mental health. Inasylums at this time manacles were applied to the arms andlegs of the patients, who were often confined in darkchambers and lay on straw. Many others were kept ingaols and served as sport to visitors at assizes, fairs, andother plices. The patients in private asylums were nobetter off, and matters at length became so bad that a com-mittee of the Houe of Commons was appointed to inquireinto the state of the private aylums of the kingdom. In1774 an Act (14 Geo. III., c. 49) was passed, bywhich five Fellows of the College of Physicians were

annually elected Commissioners in Lunacy for grantinglicences in London, Westminster, and the county ofMiddlesex. In the provinces, houses were licensed by thejustices of the peace. The medical treatment at this timeconsisted in bleeding, purging, and giving emetics, pro-bably with the idea that insanity was due to excess of bilein the blood. The views of the medical authors of that dayare interesting. Drs. Fallowes, Pargeter, Cullen, Arnold,and Mason Cox all wrote on the subject. The latter wasthe first to lay much stress on moral as accessory to medicaltreatment. Management he looks upon as of the highestimportance, and he observes that it partly consists inaddress, but principally is displayed by making properimpressions on the senses. He distinguishes between thesthenic and asthenic forms of insanity, and sees veryclearly that, though it is usual to pursue the artiphlogisticplan in the former cases, it is highly improper in thelatter, in which a generous diet, bark, and port wineare indicated. Altogether he is much in advance ofthe treatment of his time, though he believes that bleeding,blistering, and the promotion of vomiting and purging arenecessary.

In the year 1792, a year before Hunter’s death, an import-ant event occurred which proved to be the beginning of thereform that ultimately took place in the condition of allBritish asylums. It seems that there was in York at thistime an asylum which was a frightful abode for lunatic,and owing to the supposed ill-treatment of a patientconfined there, William Tuke, a citizen of the city, proposedthe erection of an institution where there should be no con-cealment, and wbera patients should be humanely andkindly treated. Hit proposition was adopted, funds wereprovided, and in 179G the York Retreat was opened and theexperiment, started. The institution was made as much aspf siblea home with cheerful surruunding. and the patientswere encouraged to work in the open air. The compassionatetreatment of the insane also commenperl in France aboutthis time, for Pinel, in the year 1793, had freed thelunatics at the Bicetre from their fetters, although hedid not know until 1798 that the same humane treat-ment was pursued in Eogland. It is generally understoodthat he did not liberate them for medical reasons, but

z’

chieflv from the compassion which he felt for their pitiablecondit on.Having given you an account of the condition of psyebo-

logical medicine during the life of Hunter, I now proceedto point out the progress which has since been made. Thesystem of treatment pursued in the Retreat was not fol-lowed for some time. Its success excited the jealousy ofthe superintendent of the York Asylum ; discussion followed,and eventually an investigation was set on foot whichnecessitated legislation. Various Acts of Parliament havefrom time to time been passed, and the result has beenthe humane treatment of lunatics as seen at the presenttime.

In 1815 a select committee was appointed to considerprovisions for the better regulations of asylums in England.Evidence was taken from various witnesses relative to thecondition of patients in the York and Bethnal-green Asylumsand Bethlem Hospital, then near Moorfields. The treat-ment at Bethlem was atrocious, and the case of WilliamNoriis, who was confined there in a barbarous manner, madea great impression upon the public mind. At the YorkAsylum cells were discovered, four in number, eight feetand a half square, perfectly dark when the door was shut,and the stench almost intolerable; in these cells thirteenwomen slept. At the Bethnal-green Asylum several of thepauper women were chained to their bedsteads, naked, andonly covered with a hempen rug. The effect of this Parlia-mentary inquiry did not then bring about a new statute.and no less than thirteen years elapsed before a radicalalteration of the law took place.In 1829 further impulse was given to the humane treatment

of patients initiated by Mr. Tuke; for, according to Conollyin his " Treatment of the Insane," in that year a patient inLincoln Asylum had died "in consequence of being scrappedto a bedstead during the night. This accident led to theestablishment of an important rule-that whenever re-

straints were used in the night an attendant should continue in the room."

"

In the year 1831 it was found that thisprinciple, which acted so well at night, was also applicableby day, and the result was that the necessity for restraintbecame less frequent. In 1835 Mr. Gardiner Hill wasappointed house surgeon of the Lincoln Asylum, and fromthis date a new era-that of non-restraint-was inauguratedin the treatment of the insane. Although the experimentwas a success, yet the remote position of the institutionand the want of authority in its author would have pre-vented its acceptance for many years if Dr. Conolly, ongoing to Hanwell in 1839, had not set to work to carry itout in the then largest asylum in the kingdom.

In 1877 a feeling of uneasiness arose in the public mind,in consequence of an impression that patients were tooeasily admitted into asylums, and when there could onlywith difficulty get out. A select committee was appointedto inquire into the subject; many false charges were made,but on strict investigation they fell to the ground. Variousproposals were suggested, which were embodied in a Billintroduced into Parliament by Mr. Dillwyn in 1881. TheBill never reached the stage of the third reading, but afterbeing introduced in successive Parliaments finally receivedthe Royal assent in 1889. A consolidation of this andprevious Acts was passed last year. The chief objectsof it are to furnish safeguards against the improper con.finement of persons as lunatics, to secure speedy treatmentand to protect medical practitioners and others in thepeiformance of their duties, to amend the law as to singlepatients, to give increased power for administeiing theproperty of lunatics, to check the establishment of newlicensed houses, and to enable public asylums to receiveprivate patients. With regard to the classification ofmental diseases various systems and principles have beenlaid down. All of them, as Dr. Blandford says, "are basedupon one or other of three principles : either they areframed according to the mental peculiarities of the patient,his exaltation, his depression, his imbecility; or they pointto a disorder of one or other portions into which the humanmind is by some authors divided ; or, the mental symptomsbeing put entirely aside, the malady is classified accordingto its pathological cause and its relations to the bodilyorganism."

" I will not weary you by recounting them, butwill simply remark that the division into mania and melan-cholia adopted by the old writers is the foundation of thewhole system, and that later advances have, as time hasgone on, been due to a more scientific study of mentaldisease.

Great progress has been made in our views of the nature ofinsanity. The old writers were of opinion that it was dueto excess of bile in the blood, and hence the bloodletting,.purgative, and emetic treatment. It would take too muchtime to study the various doctrines that have been held,but there is no doubt that the views of Laycock, Carpenter,.Munro, Anstie, Thompson Dickson, and others have all’contributed to make more clear to us that insanity is due todepression of the higher centres and excessive action ofothers. Dr. Hughlinga Jackson, adopting the hypothesisof evolution as laid down by Herbert Spencer, thinks thatcases of insanity may be considered as examples of dissolu-tion. According to this view, insanity is dissolutionbeginning at the highest nervous centres, and this is thedoctrine usually held by the more advanced scientists ofthe day. The pathology of insanity has of late years madegreat strides, and I think we have reason to hope that astime advances we may be able to establish a relationbetween the physical appearances seen after death and thelesion of intellectual functions observed during life. Ex-cluding the more recent cases of acute insanity, BevanLewis tells me that even now he can do this in epilepsy,alcoholism, general paralysis, idiocy (in this I agree withhim), chronic melancholia, senile dementia, and a largegroup of consecutive dementias, including "organic"dementia. That so much can already be accomplished is aresult of which we may justly be proud.Coming now to the treatment pursued at the present day,

we find the wards in asylums well furnished and madecheerful looking. In some parts of the country the ten-dency has been to do away with the huge buildings charac>

417

teristic of the old asylums, and to build cottages, or, in

higher class asylums, villas upon the estate. The con-ditions of life more nearly resemble those of home, and it isfound that patients can be just as conveniently classifiedand treated. In Scotland the most important change hasbeen to allow greater liberty to the patients. In someasylums the airing courts have been abolished, lockeddoors have to a great extent been disused, and many quietharmless cases are boarded out under medical supervision.Industrial occupation, especially in the open air, is of greatuse, Mechanical restraint, no doubt, in some cases cannever be abolished; indeed, this is recognised by theLunacy Act of 1890, and the Commissioners acknowledgethat cases will occur in which it is necessary for the safetyof the patient or of others, or is beneficial to the patient,that restraint should be applied. Combined with themoral treatment, which comprises the personal influence ofthe physician upon the patient, is the medical, which in-cludes the hygienic treatment. Diet and regimen are ofthe highest importance. Fatty foods, easily digestedanimal and farinaceous food, and nourishing ale and porterare useful, and though the patient may be too weak forout-door work, yet exercise, or even sitting out in the openair, is now insisted upon. The state of the bowels shouldbe attended to, and tonics, diuretics, the use of the Turkishbath and wet pack, and the bromides, chloral, sulphonal,and paraldehyde, are often beneficial. For the carrying outof this treatment, good attendants, who possess some know-ledge of mental disease, and are acquainted with a fewsimple rules in nursing, are essential. Many such are foundin all our asylums at the present day, but the Council ofthe Medico-Psychological Association have elaborated ascheme by which attendants, on going through a prescribedcourse of lectures and instruction in the wards and on suc-cessfully passing an examination, may obtain a certificate,which will not only be of use to them in passing from oneasylum to another, but will be a guarantee to the generalpublic that the possessors of these certificates have attainedproficiency in nursing and attendance on insane persons.The Council of the same association is also now engaged informulating resolutions, directing attention to what isknown as the hospital treatment of insanity. Nor shouldI omit to mention in connexion with the subject of treat-ment that a Society for the After-care of the Insane has forsome years been at work. In summing up the differencebetween the old and new treatment, 1 cannot do betterthan quote the words of Dr. Hack Tuke, who says : " Theold system believed in harshness and darkness; the creedof the new is sweetness and light."Passing now to that department of psychological medicine

with which I have for many years been closely connected-viz., the treatment of idiots and imbeciles,-I would remarkthat the idiot was a being not unknown to Hunter. Althoughthe definition he gives, in the volume of Essays and Obser-vations before referred to, is not quite correct with respectto all classes of idiots and imbeciles, yet, as little was knownabout their treatment at the time when he wrote, it issufficiently good as a general statement. The first idiotwho attracted the attention of scientific men was thesavage of Aveyron. He was a child about eleven or twelveyears of age who had lived for some time in the woods ofCaune in France, where he subsisted on acorns and roots.He was eventually taken to Paris, where he arrived in theyear 1799, under the care of a poor but respectable old man,who soon after had to leave him. Pinel, physician-in-chiefto the insane at the Bicêtre, declared him to be idiotic ;while ltard, physician to the Deaf-mute Institution, assertedthat he was simply wild and untaught, and undertook hiseducation. At the end of five years, although he hadimmensely improved the boy, Itard was convinced thatPinel was right, and gave up his task in disgust. Hislabours were, however, not so barren as he anticipated,for the principles of training and treatment which headopted still remain, but have been further perfected byothers, and by none more than by the late M. Seguin,whose treatise on Idiocy and its Treatment by the Physio-logical Method is still a standard work on the subject.The pathology of idiocy is still in its infancy, but progressis being steadily made. Mierzejewski has written an

important paper on the subject, which is also being workedat by Dr. Wilmarth, pathologist at the Philadelphia TrainingSchool for Imbecile Children. He has collected 100 brains,and has noted the peculiarities met with in each. Oneimportant conclusion has been reached-viz., that the con-

volutions of brains of idiots and imbeciles often closelyresemble those found in the brains of criminals. There isa tendency of the principal fissures to run into each other,forming what Benedikt calls a "confluent fissure type."Those who are interested in the pathology of idiocy may bereferred to an article of my own which will appear in theforthcoming Dictionary of Psychological Medicine, editedby Dr. Hack Take.Much improvement is gained by treatment. We have,

firstly, to strengthen the body and alleviate its defects, and,secondly, to undertake the special training of the mind.Having placed the patient in as good hygienic conditionsas possible, the physical training is commenced. As aresult the muscular system becomes strengthened, thehands have less difficulty in performing any simple act,locomotion is improved, the dribbling from the mouth metwith in low-class cases is less evident, the eyes wander lessrestlessly, and listlessness and inertness to a great extentdisappear. The moral training has to go on side by sidewith the physical and mental treatment. Obedience mustbe taught, and efforts made to impart good temper and ,

affection. The intellectual training in the lowest class ofidiots commences by the cultivation of the senses, and as thetactile function is the most important, we begin by educatingthe sense of touch. The senses of sight, hearing, taste, andsmell are awakened by a series of experiments, in everycase proceeding from the simple to the complex, instillingideas by the use of concrete forms and not by abstractnotions. Having educated the senses, we proceed to higherbranches of learning, and when some progress is madeinstruction is given in tailoring, shoemaking, &c., to themale patients, while domestic work and sewing prove usefulfor the females.On glancing at the future, we are led to inquire whether

there is any hope that the progress which has already beenmade in every branch of psychological medicine will bemaintained. I am of opinion that there is good ground forsuch a hope, for as science advances more and more will beknown of the structure and functions of the brain. Thelabours of Gaskell have already thrown light upon theorigin of the brain and nervous system, and those ofBetz, Bevan Lewis, and a host of others have given usmuch knowledge with reference to the structure ofthis important organ. Who, many years ago, wouldhave thought that the brain would be laid open, andpus and tumours removed from it, as is now done fromday to day ? The labours of a noble band of workershave enabled this to be accomplished, and science looksforward to still greater conquests. To stimulate inquiry inthis important branch of medicine, the Medico-PsychologicalAssociation has for some years given a prize, which is opento all assistant medical officers of asylums, for the best dis-sertation on any clinical or pathological subjects relating toinsanity. Three essays were sent in last year, and two ofthem possessed so much merit that the examiners wereobliged to award two prizes. As long as this spirit is atwork in our younger brethren, we can with confidence lookforward to 1uture discoveries. The knowledge of psycho-logical medicine should, however, be still more extendedamong all branches of the profession, so that those towhose lot it may fall to treat mental diseases at itscommencement, when remedial measures are most valuable,may be able to apply their knowledge with benefit tothe patient and advantage to themselves. Inquiries intothe causation of insanity should be pushed still further,more attention should be paid to the laws of inheritance,endeavours should be made to impress upon those who arethe subjects of this damnosa hcereditas the utmost import-ance of paying attention to the laws of health, and teachersshould be warned against unduly pressing and overworkingthe brains of growing children. Let us remember the oldmaxim, "Ars longa, vita brevis," and, whatever our medicalpath in life may be, let us see that we hand down the flamingtorch of knowledge pure and undimmed to our successors.

" Let us then be up and doingWith a heart for any fate ;

Still achieving, still pursuing,Learn to labour and to wait."

THE EASTERN HOSPITAL.-Dr. Bridges and Mr. R.Hedley have been appointed by the Local GovernmentBoard to hold an official inquiry on oath into the complaintsagainst the management of the Eastern (Homerton) Hospitalof the Metropolitan Asylums Board.