In the present paper I do not intend to deal with those graver affections, such as apoplexy or paralysis, which frequently occur in the aged, and which depend on gross lesions of tissue. Nor shall I mention the severe and intractable neuralgias of advanced life. I desire to direct attention to a class of neuroses, which more or less inevitably attend the decline of life, and which, though they do not involve any serious catastrophe, are the cause of so much suffering that it is surprising that they should have received little or no systematic notice from medical writers. The neglect of these complaints is not merely a negative evil; for, owing to the fact that their neurotic nature is ignored, certain superficial symptoms which they present are treated as if they depended on functional disturbance of the liver, or ordinary stomach catarrh, &c., and very often with depressing remedies, which greatly aggravate the existing evil.

In the Annual Report of the Rainhill Asylum, the Medical Superintendent, Dr. Rogers, makes the following excellent remarks in regard to accidents in asylums, and the unjust accusations that have been based upon them:—

Since the publication of Bender's (3) “Visual-Motor Gestalt Test and its Clinical Use” many attempts have been undertaken to validate the clinical findings which she outlined in her Monograph.

In his “Tentative Guide to the Administration of the Bender-Gestalt Test” Hutt (7) did more than anyone else to put into practice the clinical use of the Bender-Gestalt, but his finding on Psychoneurotics have not been confirmed by empirical studies. However, it is of interest and encouraging to find many of the subsequent empirical studies substantiating most of the original clinical uses outlined by Bender and Hutt.

There is a type of social psychology which finds the explanation of man's social behaviour in a hypothetical “disposition” of his mind. This motive-complex is conceived as specialized for the function of adapting conduct to social life, and as being in itself relatively closely integrated, developing and functioning as a whole. Of this hypothetical “gregarious instinct” McDougall goes so far as to say: “For it is highly probable that instinctive dispositions are Mendelian units” (Journ of Abn. Psych, and Soc. Psych., vol. xvi, p. 316). This plainly suggests that the unity of the social disposition (its existence as a discrete factor in development) is to be regarded as antedating experience—that it is an ultimate datum for psychology not susceptible to analysis, and is not a derivative of any other known motive such as “love,” “fear,” or “hope of reward.” This “instinct” interpretation of social behaviour has been criticized on many grounds (as unfruitful for psychology and incompatible with biological fact); but of course the demonstration of a Mendelian transmission of the social disposition would compel us to regard it as an element of character. Our conception of mental development and of the “socialization” of the individual, of the relative significance of upbringing as compared with organic endowment and our whole psycho-pathology depend upon our acceptance or rejection of McDougall's view. If he is right in regard to the germinal “unit” determination of the social disposition, criminological studies should offer verification. I propose, therefore, to consider how far we are justified in regarding moral insanity and moral imbecility as true “morbid entities.”

As katatonia, “a mental disorder,” writes Spitzka, “well marked but not generally recognized,” has hitherto received but scant notice in this country, the following observations, based on the study of a group of cases which well illustrated its alleged characteristics, may not be devoid of interest.

The following observations are founded upon the records of 301 autopsies performed by myself at Rainhill Asylum. They are concerned principally with certain abnormal and morbid manifestations which occur within the crania of the insane. Of these the chief are, on the one hand, indications of subevolution, as shown by macroscopic structural defects of the cerebral hemispheres, such as deficiency of weight or of convolutional complexity, and on the other, evidence of dissolution as exhibited by wasting of the cerebral hemispheres. The relationship existing between these abnormal and morbid manifestations and certain other intracranial appearances is also discussed. No attempt, however, has been made—for reasons which will afterwards be given—at any close correlation between these abnormal and morbid manifestations and the mental states recorded during life. The observations, therefore, are of a pathological rather than a clinical nature.

It has been said by some astute critic that “insanity has no pathology,” but it would be a nearer approach to scientific truth if he had said that, with our present imperfect means of investigation, there are many cases of insanity in which no pathological changes can be discovered as the cause of the mental phenomena. The microscope, for example, has as yet failed to differentiate the delicate alterations in the protoplasm of the cerebral cells which result in an outburst of maniacal excitement; nevertheless, the ophthalmoscope shows changes in the vascular supply of the brain in many such cases, and, with the aid of the sphygmograph, light has been thrown on many hitherto obscure conditions of the circulation.

The mental hospital of to-day has developed in stages from the earliest of which we have any particulars.

Progress in planning and design has been gradual, with periods during which it has been pronounced. Each period has shown an advance in the lay-out and detailed arrangement of the buildings to meet the coincident advance in methods of care and treatment of the patients.

Skin sensitivity had been mentioned and demonstrated in isolated instances over a long period of years before Schloss in 1912 extended and described its usage and established it as a definite means of detecting hypersensitiveness. Since then it has been universally recognized as a most useful adjunct to the study of the aetiological problems of allergy. At first it seemed that a miraculous means had been found of explaining both the cause of and the reason for the recurrence of certain common disorders of obscure aetiology in widely separated organs. It promised to show how totally different symptoms could be attributed to a common agent. The fact that the skin was sensitive but that the only clinical evidence of disease appeared, say, in the lungs gave the impression that all organs of the body must be in a like state of sensitivity. This has since been widely disputed and denied and on this subject Alexander (1936) states that such an assumption, at least from the clinical standpoint, is a fallacy. Man, he believes, may exhibit general hypersensitivity if a sufficiently large dose of protein be experimentally introduced.

If, then, hypersensitiveness is localized in certain tissues, it follows that the skin may or may not be sensitive in any given case and at any given time. In other words, because the ingestion of a specific food leads to colic or urticaria, it does not necessarily follow that the skin will give a positive reaction to an extract of that food in all cases or at all times. Indeed, a positive reaction may not occur at any time. This limitation of skin testing is now accepted; but nevertheless, allowing for the fact that only 50-60 per cent. of allergics (and that is not an over-generous estimate) give positive results, it still remains a very valuable diagnostic aid.

Since the following Paper was commenced, the appearance of the “Report from the Select Committee on Lunatics, ordered by the House of Commons to be printed, 27th July, 1860,” of which Committee Mr. Walpole is the respected Chairman, has, in a considerable degree, relieved the minds of physicians practising in the department of insanity, from the apprehensions occasioned by the draft of a Bill ordered to be printed in February, 1859. It would seem that the evidence brought before the Select Committee in disparagement of the proprietors of asylums for the insane, and in support of the alleged fact of the improper detention of persons in a state of sound mind, was deemed insufficient to warrant the meditated additions to stringent restrictions already existing. All the obnoxious clauses relative to the appointment of Medical Examiners, a kind of unqualified auxiliaries to the Commissioners in Lunacy, and who were to make secret reports, have been abandoned; as well as some other clauses, which had been the source of great and just dissatisfaction.

The following two case-records furnish an interesting example of similar mental illness occurring in identical twins, in which, however, in the one case the illness had come on endogenously, whereas in the other there was an apparent precipitating cause. Their age when seen was 25 years.

That there are two methods by which to approach the study of mind—the one inward and reflective, the other outward and transitive, including more especially the anatomy and physiology of the brain and nervous system—is by high authorities, even in physical and biological science, now generally admitted.