H.—7

6

that subject now fittingly revert. In the centres of population at any rate there should be sufficient encouragement for medical men to specialize, and when, in course of time, psychiatic wards are added to ordinary hospitals, to take charge of these, treating there —and this is most important— only those cases which can be properly treated in such wards. Diploma in Psychological Medicine. —These observations lead to a subject which the Otago Medical School may consider—namely, examining for this diploma candidates presenting certificates of having fulfilled requirements with regard to courses of study. In the meantime, and for many years to come, the number of graduates which would attend a special course of lectures and demonstrations would be too small to encourage the University to be anything more than an examining body; but with a neuro-pathological laboratory, which Dr. Alexander tells me he would willingly place at the service of graduates, and the resources of the Dunedin Hospital, the University, and the Seacliff Mental Hospital, any one anxious to qualify for the diploma would get assistance from teachers in practically all the subjects. The curriculum laid down by the Medico-Psychological Association, and approved by the Commissioners in Lunacy, by the principal universities of Great Britain, and by the Royal College of Physicians, is made up of five obligatory and a choice of one of five optional subjects as follows .-— Obligatory. —(l) Anatomy, physiology, and Pathology of the Nervous system; (2) psychology, normal and morbid; (3) clinical pathology; (4) clinical neurology; (5) psychiatry, systematic, clinical, and medico-legal. Optional. —(l) Experimental psychology; (2) bio-chemistry; (3) bacteriology; (4) comparative anatomy and physiology of the nervous system ; (5) eugenics. About the practicability of the University examining, and granting diplomas, I am not in a position to express an opinion—l merely throw out this suggestion for what it is worth; but I have no uncertainty about the special knowledge required by those who have to advise on the care and treatment of the insane. More particularly is such special knowledge essential when it can be exercised before the malady becomes confirmed, and, if possible, at its inception, if not when still more timely counsel is of use. Causes of Insanity. —These have been well epitomized by Mercier as heredity and stress in inverse ratio. Heredity —that is, the inherent tendency—may be derived only from insane ancestry, but persons labouring under allied neuroses, the epileptic, hysterical, neurasthenic, transmit an inheritance which, given the requisite stress, produces insanity. Alcohol and some \ other toxins operating upon parents lower the ratio of stress necessary to produce unsoundness of mind in the offspring To effectually prevent the transmission of such heredity by State interference save by extending the definition of persons who may be brought under oversight, care, or control, is, in the meantime, outside practical politics, and must wait that growth of public opinion which develops into reform. When the public is really alive to the value of eugenics, perhaps legislative interference will not be necessary. As to the factor of stress, one has to aim at modifying inherited weaknesses in order to raise the ratio which can be borne without untoward result--a matter not so much of tempering the wind but of hardening the shorn lamb. Stress may be applied by the environment in the form, say, of financial disaster, poisoning by alcohol, and so forth, or it may generate within the system, as, for example, in the form of unaccustomed sensations of growth and decay associated with critical periods, or of poison produced in or not eliminated from the body owing to physiological error or pathological changes. Commonly, many forms of stress act at the same time, act and react, till the searcher after causes finds himself in a labyrinth. To differentiate and disassociate these, and lead to the path which becomes simple when known, we look to the guide, the investigator in his laboratory. For statistical purposes the principal assigned cause in the case of admissions is given m Table XIII in the Appendix, and hereunder these have been summarized with the proportion per cent, under each heading. Under heredity are cases in which no other cause was given or the other cause was quite inadequate. The physiological unfitness of the particular organism to bearstress is well exemplified if we take one of the headings and analyse it. It will be seen that nearly 7 per cent of the women admitted became insane through the performance of functions for which woman is anatomically and physiologically designed, and in the performance of which the normal woman could not have her reason disturbed. Male. Female. Total. Heredity 14-32 14-63 14-46 Congenital deficiency ... ... ••• 8"95 8-51 8-75 Previous attacks " 738 11-17 9"1 I Critical periods , •■• 1342 lo'l6 H'22 Child-bearing ... ... ••• 6 9 ? f*° Mental stress 8"28 IM7 9-60 Physiological defects and errors ... ... 4-47 U6O 316 Alcohol ... 17-90 4-26 11-66 Other toxins 5-87 345 4"49 Traumatic ?-46 053 I'sß Diseases of the nervous system ..: ... 0 - »2 o 05 a it SLIT 5 ' di ~" ::. ■:: :» » S 100-00 100-00 100-00