Friedrich Nietzsche was descended from a noble Polish family which sought refuge in Germany from religious persecution. His ancestors on both sides are reported to have been healthy and long-lived. His father was a Lutheran clergyman, his mother the daughter of a clergyman. He was born on the 15th of October, 1844, in the parsonage of Röcken, in Prussian Saxony. His father laboured under a cerebral affection for eleven months, and died when Friedrich was five years of age. His sister, Frau Förster Nietzsche, tells us that this was the consequence of a fall on the head; but Friedrich stated his belief that his own nervous disorders were inherited from his father.

General paralysis of the insane was first described by Haslam in 1798, thus its recognition is now a century old; and although an enormous amount of labour has been devoted to the search for the essential cause of this disease—perhaps the most fatal to which human flesh is heir—opinion is yet far from unanimous as to its origin. There is no doubt that the view that syphilis is the prime cause finds most favour at the present time; but in view of the want of uniformity of opinion on this matter, I have felt that a serious attempt to arrive at a definite conclusion would be welcomed by the alienists of this country. Such an attempt might at least help to clear the ground for future investigation.

I propose in this address to call your attention to some phases of mental disorder which depend on toxæmic states. These are now differentiated by the alienist, and it is only in recent times that their true nature has been unfolded. They have been long recognised as clinical features of disease, and the sources of them are as varied as are the separate toxic elements which induce them. Progress in physiological chemistry and bacteriology has now furnished us with the means to explain these conditions. The origin of these toxins is at least threefold. They may be generated in the body (auto-intoxicants), or by the malign working of microbes introduced from without, or they may arise by impregnation with organic poisons, or yet again result from the habits of alcoholism, chloralism, cocainism, and morphinism. In the majority of cases of insanity I suppose it will be conceded that there is a hereditary or inborn predisposition to the disorder, an instability or a tendency to this cerebral degeneration which may remain latent until conditions arise which are potent to elicit the breakdown. In the class of mental disorders we are now to consider there may or may not be this inherited fault of brain tissue. In many instances of toxic insanity we have to deal with persons who are already predisposed to mental instability, but in other cases a previously normal brain may be so damaged by toxic influences as to manifest aberration. We have long recognised the toxic effects on the nervous system of the altered metabolism induced by renal inadequacy in Bright's disease in the varied forms of uræmia, in that strange variety of autotoxy due to inability of the hepatic and muscular tissues to hold carbohydrate in reserve, resulting in diabetic coma, and that variety which depends on acute atrophy of the liver. We can now understand how these auto-intoxications act in disturbing the harmony of intimate brain-cell metabolism. Their effects are as certain as are those of poisons directly introduced by the mouth or under the skin. The chemical functions of the brain cell are disordered in precisely the same manner. In the ordinary practice of medicine we are familiar with states of delirium and mental aberration in the course of the various fevers and in pneumonia. Recognising these as infective disorders we now know that we are dealing with the toxic effects of invading parasites, and that amongst the manifold expressions of their presence are nervous or brain symptoms. These are frequent in pneumonia, and strangely so when the pulmonary apex is involved. The reason for this is to me inscrutable, and I can only conceive that it results from some special local nervous relations which have hitherto escaped the recognition of the physiologists. With respect both to pneumonia and the various fevers, I have to add that a careful inquiry in cases where grave nervous or mental symptoms have supervened, has almost always revealed the existence of personal or family neuropathic taint. Puerperal insanity occupies precisely the same position, and inquiries in these cases show that about one half of them occur in women of neurotic or insane proclivity. Toxic influences naturally affect them more readily and with greater gravity. The insanity of lactation probably owns a different cause, and may be attributed to debility and imperfect nutrition, acting probably in many cases upon an originally unstable brain. What has been termed “post-operative insanity,” due to infective influence, together with shock or exhaustion, and occurring within a few days after operation, may be similarly classified, although Mr. T. C. Dent is of the opinion that heredity of brain weakness plays but a small part in these cases, and that some of them apparently result from the influences of the anæsthetic agents employed or from iodoform impregnation.

In a previous paper has been demonstrated the possibility of localising the fundamental emotions in circumscribed areas of the cortex of the brain.

I propose to deal with this subject under the three following heads:

1. 1. What the Act was expected to accomplish.

2. 2. What it is accomplishing.

3. 3. What an adequate Inebriates Act ought to accomplish.

First, then, what was the Act expected to accomplish?

Dr. Weatherly, in introducing a discussion upon the above subject, said its gravity would perhaps appear to them greater when they were told that in one town of England, such as Liverpool during last year, every time the clock hand went round and indicated that another four hours of time had gone by, a life was passing away in that town from consumption; when they further were told that in that one town of Liverpool more young people died of consumption in 1899 than had up to the present been killed in South Africa during the present war. The great thing, however, for them to think of to-day was, “Is there any need to do anything with regard to phthisis in our asylums?” Once they accepted that there was; then came the question, “What was best to be done?” The premiss upon which he should like to start the discussion that day, was a sentence uttered in London a short time since in a most able speech by Sir James Crichton Browne, in a discussion which took place following the paper by Dr. France. He said, “Phthisis is prevalent, and is the cause of death in our public asylums in this country to an unnecessary extent,” and he went on to say that “it was to a very considerable degree generated and propagated in them.” It was known that young healthy people with possibly a predisposition to-phthisis entered asylums, became phthisical patients, and propagated disease far and wide. The first question asked would naturally be, “Why is this?” This brought them, to his mind, to the most difficult position in which they found themselves. Personally he did not think there could be any doubt that what Dr. Cruikshank in his prize essay said was absolutely true, viz. that it was due first and foremost to overcrowding; secondly, to lack of sufficient exercise and pure air; and thirdly, to a certain quality of dietary. These were the three reasons he brought forward, and which were very much emphasised by Sir James Crichton Browne. With regard to overcrowding, he thought the modern tendency of piling building on to building at their big asylums was one that ought to be very greatly deprecated. With regard to the lack of exercise and pure air, one had no doubt always felt there were difficulties in the way. It seemed to him that every patient should be made to live during the greater part of the year a great deal more out of doors than was the case at present. This was more especially necessary in the case of women, among whom they found phthisis much more prevalent than among men. Those who were not strong enough to take exercise might have shelters made for them in which they could lie or sit. Another question was whether or not a definite rule might be made in all asylums that during certain periods of the day every single inmate of the ward or corridor should be taken out of those corridors or wards, and a free draught of fresh air with open windows be allowed to circulate through every part of it. He believed there was nothing so good as a direct ventilation of pure air through the windows of their wards; but he was persuaded that the greatest thing for them to discover in England was how to get efficient direct ventilation without draught. He saw no reason why the windows of all asylums should not be made with the bottom part to open outwards or inwards, as a French window, whilst the upper part was a flap window, opening outwards or inwards as desired. Dr. Weatherly went on to describe this window more in detail. With a window like that they might always keep the upper part open, and obtain any amount of fresh air without any possible draught In dealing with the question of the quality of the dietary, he was aware that he was touching on a very tender point. It seemed to him, however, that it was a very sad thing that there was an inclination on the part of management committees to pat on the back a superintendent who was able to show that he could keep his expenses per head of maintenance at a very low rate. (Hear, hear.) He felt very seriously that if committees of management spent a little more money on a more generous dietary—he would say nothing about the quantity, that was ample, but in obtaining a more varied, more nutritious and fatty dietary—it would be a very great benefit. If they spent a little more on the food of the patients, and a little less on palatial buildings, they would be doing far more good in checking the spread of this terrible disease. (Hear, hear.) With regard to what could be done, first of all, to prevent the starting of phthisis, he would suggest that the number in the building be lessened. Then there was the tremendously difficult question of the expectoration. They did not find it impossible to inculcate cleanly habits in the case of dirty patients who entered their asylums, and he could not help thinking that if they adopted some such rules as were in force in different sanatoria for the treatment of the disease, beneficial results would follow. He advised the placing of spittoons fastened by locked rings in all corridors and wards, utensils by all bedsides; the posting of rigid rules, and the provision of some form of handkerchief for expectorating purposes which could be thrown away and burnt at once. Difficulties would arise, he knew, but he believed that by these means much good would be done. In the sanatoria in Germany rules were posted on the walls in all parts of the building to the effect that any one found spitting on the floor of the corridors or rooms, or outside on the walks, would be discharged, and, although they might be paying four or five guineas a week, they were sent away if they persistently disobeyed this rule. Then the nurses had also definite rules given them. They had always disinfectants handy, and a sort of mop with rag or soft paper at the end, which could be burnt after use, and with which if they saw any expectoration on the floor they could, after applying disinfectants, immediately mop it up. Another great difficulty they had to contend with was the diagnosis of phthisis in their patients. They found that in ordinary cases the most skilled physicians had a difficulty in diagnosing this terrible disease in its early stages, how much more difficult was it then in asylums for the insane! Dr. France and Dr. Cruikshank both suggested that medical officers of asylums should keep a very strict look-out upon the weight of their patients, and also spoke about monthly weighing. Personally he thought they ought to go a step further, and weigh their patients once a week, particularly in cases where it might be found they were not taking their food properly. The question of temperature was also a most important one. The old idea used to be that one of the distinguishing symptoms of phthisis was the evening temperature of the patient rising higher than the morning. He could say from his own experience that such an idea was quite fallacious. A patient with a temperature normal morning and evening might possibly have a temperature of 102° at 12 o'clock in the day. There was absolutely no rule, except that in some period of the twenty-four hours there was fever. If they wished to diagnose phthisis, he advised that the temperature be taken in the morning, again at 12 o'clock, at 4 or 6, and also the last thing at night; and then if they found at any of those periods the temperature rising above normal, they should be very suspicious. He would not dwell upon the tuberculin test because that had already been threshed out pretty exhaustively. An important question which they had to consider, however, was what they could best do when they had the least suspicion of having a phthisical patient in their midst. He believed this to be a matter which they must grapple with definitely and decidedly. They had to deal, first and foremost, with a phthisical patient, and secondly with an insane phthisical patient; and it became absolutely necessary that whatever sanatoria treatment they adopted must be in the shape of another asylum for those patients. He would say generally that no definite rule ought to be made. The site of one asylum might have ground of easy access, in every way applicable to sanatoria, while in the case of another it might be that it would be impossible or entirely wrong to build a sanatorium near. To ensure success they required to be built on sandy or gravelly soil, which dried quickly, with woods where the patients could have sheltered walks, and with a south aspect, in order that the dwelling and sleeping rooms might be protected absolutely from the north and east winds. There was nothing which handicapped the treatment of phthisical patients more than bronchitis, and there was nothing more calculated to give bronchial catarrh in phthisical cases than when the patient was subjected to northern or easterly winds. Then came the question whether it would be feasible in some cases for two county asylums to join hands in the matter and have a decent sanatorium which should be within easy distance of either, with its own medical officer. He was strongly of opinion that to build small detached cottages for such a purpose would be a waste of money. By removing phthisical patients from their asylums, and treating them in other buildings, they would, he suggested, be going a long way towards solving the difficulty which now existed in many cases of lack of accommodation for ordinary cases. His own feeling was that they could build a suitable sanatorium in England at £200 a bed, and give each patient a separate room to sleep in.

I need hardly apologise to you for my appearance once more before you as a reader of a paper, yet I think it well to give you my reasons for selecting this subject for to-day's discussion. For years past I have been feeling more and more strongly that travel as treatment was being carried too far, and having often in private expressed this feeling, I think it right to assert my belief here, fully recognising that I may be looking at the subject from a wrong standpoint, and being quite ready and willing to learn by the experience of others. I recognise in myself a tendency to believe in my own experience, and thus I may be warped.

Is there any special connection or affinity between insanity and phthisis? In other words, is there a greater proclivity in the insane because of their insanity to develop pulmonary consumption than in the sane? That such is the case is, I think, an opinion which at least up till recently has been rather widely if somewhat vaguely held, and believed to be well grounded. The ablest contribution on this subject has, I need hardly say, come from the pen of Dr. Crookshank (Journal of Mental Science, October, 1899), and the facts and arguments adduced by him should go far to dispel this idea. In this paper no attempt will be made to treat the question fully, which, after all that has been written by others, would be quite superfluous, but I shall endeavour, mainly by an appeal to some statistics of Irish asylums, to see if from them corroboration is to be found for Dr. Crookshank's conclusion on this particular point. My paper is therefore to be regarded as in a small way supplementary to his.

In the series of observations made, the best marked examples of each type of insanity were taken; great care was taken to exclude the presence of inflammatory and other pathological conditions, and also physiological blood changes were as far as possible excluded, e.g., those resulting from the ingestion of food.

In the year 1896 I directed the attention of my fellow specialists, in the course of details of observations relating to two women, to the subject of pathological dreaming, till now only slightly investigated, and showed how intense hysterical dreaming states had been developed from previous reveries. The literature which has appeared since then contains but few references to this matter.

To anyone watching carefully the figures given in the last five annual reports of the Commissioners in Lunacy for England it is quite apparent that one very distinct and unmistakable change has during each of the five years ending 1897 been taking place in the character of the admissions into asylums. There is no indication that lunacy is diminishing, rather the reverse, for the proportion of the average annual admissions in which the attack is stated to be the first, i.e., occurring insanity, which in the quinquenniad 1888–92 was 3·7 per 10,000 of population, rose to 4 in the five years ending 1897. The change of type in the admissions to which we refer is the diminution in the proportion of general paralytics. Not only is this characteristic of the quinquenniad as a whole, but it applies to each of the individual years, the percentage proportion for each five-year period ending with that for 1893–7 being 8·7, 8·5, 8·4, 82, 7·8. The change is all the more striking inasmuch as each of the three quinquenniads preceding this one was characterised by a steady increase in the occurrence of the disease, so striking, indeed, that one might have supposed that the Commissioners would have been justified in making a much more affirmative pronouncement than the one they do in their Fifty-third Report, viz. that “it would not appear that general paralysis is increasing in the general population.” Not only is it not increasing, it is diminishing, and that, too, progressively, during the past five years.

It gives me great pleasure to have an opportunity of bringing to the notice of this meeting some matters connected with electrical treatment, because I believe that in the management of mental cases a very suitable field of application may possibly be found for electricity.

All the facts which can be gathered from the study of museums or literature point to the conclusion that the sense of light was developed first, then the sense of colour. The tendency has been to regard colour-blindness as “chromic myopia;” but this is not correct unless there is a defective perception of light as well, as shown by the cases which I have recorded. A man may be able to see light of all colours at twice the normal distance, and yet be colour-blind. I specially wish to emphasise the fact that there is no definite relation between light and colour. When light falls upon the eye it sets up a nerve impulse, which is conveyed to the brain. In the impulse itself we have the physiological basis of light, and in the quality of the impulse the physiological basis of colour. My contention is that these two factors are perceived by two entirely different sets of cerebral cells, those devoted to the perception of colour being developed at a later period than those conveying to the mind the sensation of light. All the evidence which can be obtained shows that all objects were first seen as in a photograph, that is, in different degrees of black and white. In the evolution of the colour sense those waves which differ most physically, namely, red and violet, were first recognised as different, the remainder of the spectrum appearing grey. Homer's colour vision was of this class, which represents the degree just preceding total colour-blindness. I have recorded a case of this kind of a man who was colour-blind with one eye, and who was therefore able to tell me exactly how objects appeared with this eye. He said that the spectrum appeared nearly all grey, but with a tinge of red at one end and a tinge of violet at the other; he could see very much better with the colour-blind eye than with the other.

In this brief sketch it is my intention to refer to a few of the points which I regard as having an important bearing on the construction of asylums in tropical countries.

As the mode of dealing with those insane persons who have committed offences bringing them under the authority of the criminal law differs in some respects from the practice followed in the case of the ordinary or non-criminal insane, I thought that on the occasion of the visit of the South-Western Division of the Medico-Psychological Association to this Asylum a brief outline of the history of the arrangements for the care and supervision of the criminal insane in England might perhaps be of interest to those members who have honoured Broadmoor with a visit to-day.

In view of the fact that a considerable amount of confusion exists in the mind of the profession as regards recent legislation for inebriates, I have ventured to bring this somewhat dry-as-dust subject before the readers of the Journal of Mental Science.

In approaching the subject-matter of this paper I am fully conscious of its importance and the difficulties to be contended with in dealing with such a vexed question, the far-reaching effect of which must of a necessity materially influence the financial position on retirement of thousands of asylum officials of all grades. In adopting the question of superannuation I do not think I could have selected a better or more useful one for the purpose of calling attention to the provisions of the Acts of Parliament which determine the retiring allowances in this country, and the similiar Acts operating in England and Scotland, and, at the same time, eliciting an opinion as to how our common interests could be best served in getting rid of the permissive clauses common to all the Acts.