I have to thank the Council of the Society for their kindness in appointing a day for the discussion of the question which is the subject of the following paper. The paper has been written at the suggestion of my friends Dr. Clouston and Dr. John Macpherson; but it is right to say, as they have left me a free hand in dealing with the subject, that they are not to be held responsible for the opinions it contains.

The existence of pellagra in Egypt has been pointed out within recent years by Dr. F. M. Sand with, and for a description of the disease as it occurs in hospital practice reference may be made to his articles.

The honourable position which your courtesy rather than any merit on my part has placed me in, carries with it the privilege of addressing you, and in offering you a few remarks on some of the problems of heredity, more especially with reference to their bearing upon insanity and allied conditions, I am fully conscious how inadequate my knowledge is to treat with satisfaction so important a theme. I venture to hope, however, that a few facts and theories bearing on this subject may not be devoid of interest, and may possibly serve as a stimulus to additional inquiries in this direction.

“The wicked flea,”—Everybody knows the “wicked flea,” for it is no respecter of persons. It makes its home in the palace of the prince, the hovel of the savage, and the tent of the Arab. The devotions of many a worshipper are destroyed by the Pulex tabernaculi, or church flea, which makes up by its voracity on Sundays for enforced abstinence on other days of the week; and one of the wonders narrated by travellers is that on camping in the desert they have found this wicked little creature waiting for them, ready to bite, although apparently its progenitors from time immemorial could hardly have had an opportunity of gratifying their taste for blood. When in Rome one summer, fleas were abundant in the hotel where I was staying. I used to walk barefooted about my room every morning, and soon a prick on the instep would warn me that a flea was there. I looked down, saw a little black speck, put a wet finger upon it, and after a little rub would transfer it to a basin of water. The sensation of something solid between the finger and thumb and the transference of the black speck from my instep to the water convinced me of the presence of the flea, for I had the threefold evidence (1) of common sensation, (2) of sight, and (3) of muscular sense all combining to prove the actual existence of the flea. At other times during the day I had the evidence of sensation to indicate to me that fleas were again biting, and I felt quite convinced by sensation alone that such was the case, for although I could not corroborate the evidence of sensation either by sight or by muscular sense, yet it was not contradicted by these senses. But sometimes I have felt upon my hand a sensation exactly similar to the bite of a flea, and yet, as the hand has been on my writing-table within full vision, and no object whatever was to be seen on the hand, I have discarded the evidence of sensation in favour of that afforded by sight, and come to the conclusion that no flea either was or had been upon my hand. Had it not been for the sensation of sight, however, and had the hand been hidden from my view, I should have confidently believed that it had been bitten, trusting to the evidence of sensation, which, though unconfirmed by sight or muscular sense, was not contradicted by these senses.

An inquiry into the condition of the various organs of those dying insane cannot fail to be of interest to those who believe that mental disease and physical disorders are, in the majority of cases, closely associated.

About the time that this very interesting specimen came under notice, the members of the Medico-Psychological Association were being treated to an able exposition of the present-day views on the burning question of the localisation of mental functions. The intention of this short contribution is very humble, my main object being to explain the specimen, and while doing so to offer a few general observations on any bearing it may be thought to possess regarding the localisation of intellect.

The title of my paper is almost a platitude, for we all know from experience that stimulus is essential for the generation and regeneration of nerve structures and function; and that the importance of stress (excess of stimulus) incidental to modern civilisation and town life in the production of nervous diseases and insanity is beyond dispute; yet when we are asked to give precise data to prove these premises, the matter is not so easy.

Before giving a description of the particular methods of caring for the insane in use here, to which attention is to be drawn, I consider a statement of the general principles underlying these methods a necessary preliminary, in order to place the reader in touch, if not in sympathy, with my motives, and to enlighten him as to my objects.

In the communication which I have the honour to submit to the members of the South-Western Division to-day, I intend to bring forward some facts and some figures, not hitherto recorded, relating to the female patients now and formerly resident at this asylum.

A paper upon the subject of “Night Nursing and Supervision in Asylums,” by Dr. Middlemass and the writer, was read at the Annual Meeting of this Association in 1899, in which the practices pursued and the results obtained at the Sunderland Asylum during a period of four years were fully dealt with, and it was advocated—

The minute study of morbid organisation as a factor in the genesis of crime which has been extensively pursued in recent years has been for the most part concerned with conditions of arrested or distorted cerebral development, with the different forms and degrees of innate defect. Less attention has, on the whole, been given to the other large class of neuropathic criminals, those in whom the morbid aptitude for criminal acts is connected with deterioration of brain, where the mental defect is acquired.

Mr. President and Gentlemen,—While recognising the undoubted fact that what may be called ordinary insanity has no demonstrable lesion, the disorder being in the “subtle chemistry of the nerve-cells, and that no surgical procedure can correct aberration in tissue chemistry,” I still think there are a small number of cases, not only of traumatic but also of non-traumatic origin, in which surgical treatment may have beneficial results.

Dr. Orr has shown you the normal cells of the posterior root ganglia and the changes which they undergo in general paralysis of the insane, and we have thought that it would be of some interest briefly to follow the subject a little further, and to see what is the modem view of the degenerative changes in the cells of the posterior root ganglia and in the nervefibres of the spinal cord in general paralysis and in tabes dorsalis.

Dr. Clouston said: I shall endeavour to keep in mind that my duty is to initiate discussion, and not to attempt to read anything like an exhaustive paper. Since my friend Sir John Sibbald has treated this subject in a full and careful manner from the historical and other points of view, I shall put it in the form of a series of questions and short answers.

Dr. Clouston said that when he suggested toxæmia to the secretary as a suitable subject for a discussion at this meeting he had not intended to be the first speaker, because his object was to bring out more fully the views of the younger members who had recently committed themselves so strongly to the toxæmic and bacterial etiology of insanity, and so to get light thrown on some of the difficulties which he and others had felt in applying this theory to many of their cases in practice. It was not that he did not believe in the toxic theory as explaining the onset of many cases, or that he under-rated its importance, but that he could not see how it applied so universally or generally as some of the modern pathological school were now inclined to insist on. He knew that it was difficult for those of the older psychological and clinical school to approach the subject with that full knowledge of recent bacteriological and pathological doctrine which the younger men possessed, or to breathe that all-pervading pathological atmosphere which they seemed to inhale. He desired to conduct this discussion in an absolutely non-controversial and purely scientific spirit. To do so he thought it best to put his facts, objections, and difficulties in a series of propositions which could be answered and explained by the other side. He thought it important to define toxæmia, but should be willing to accept Dr. Ford Robertson's definition of toxines, viz., “Substances which are taken up by the (cortical nerve) cell and then disorder its metabolism.” He took the following extracts from his address at the Cheltenham meeting of the British Association as representing Dr. Ford Robertson's views and the general trend of much investigation and hypothesis on the Continent.

Although hallucinations are so common and universally recognised as an indication of insanity (Esquirol reckons, probably truly if we count every stage of every case, that they occur in 80 per cent. of cases of mental alienation, and we all know that even with the general public there is no proof of aberration more convincing), yet there are many points connected with the study of hallucination which are worthy of more attention than they generally receive.