Two years ago, when the toxic theory of the causation of insanity was attracting attention in this country, I made a series of observations on the blood of acute recent cases of insanity with the object of ascertaining whether organisms were ever present. In no case, with the exception of one of general paralysis, did I ever find an organism in the blood. It occurred to me, however, that if I could make an aseptic necrotic area subcutaneously, the serum and pus in such an area would be a suitable nidus for the growth of organisms circulating in the blood, and that by aspirating the serum and pus and placing it in suitable nutrient media one should be able to grow such organisms, if present. Acting upon this theory, I took a case of acute mania—an adult woman—and, with antiseptic precautions, injected into the soft tissues of the flank 2 c.c. of turpentine.(1) An abscess formed, and on the third day after the injection I aspirated some fluid, consisting of blood-serum and pus. A couple of drops of this fluid were then added to each of four tubes containing 8 c.c. of sterile nutrient broth. These tubes were incubated for forty-eight hours, when they showed slight turbidity, and upon microscopical examination the broth was found to contain a pure growth of a small diplo-bacillus.

Although much has been written upon porencephaly, yet detailed descriptions of the resulting alterations in the constituent neurons of the cerebro-spinal axis are few in number. As a further contribution in this direction the present case has been studied, and the changes found have been recorded as far as possible graphically. No attempt has been made to collect together the literature, largely clinical, of porencephaly, as it has been felt that this cannot be profitably done until the minute anatomy of the central nervous system has been placed on record in a much larger number of cases than is at present available

Gentlemen,—In commencing the work of the office to which you have elected me, I desire to convey to you my sense of the honour conferred and of the responsibility which this honour entails. In heartily thanking you, I assure you it will be my constant care to maintain impartially the rights of members and the freedom of debate. While checking exuberant verbosity, I shall endeavour to encourage useful discussion and to expedite business at all our meetings, and shall look to you for the support which is necessary to preserve intact the dignity and privileges of the Chair.

The case here dealt with is that of a man æt. 35, now a patient at Carmarthen Asylum, formerly a ferryman. He was admitted from prison, where he was undergoing a sentence of twelve calendar months with hard labour, having been convicted at the assizes of unlawfully attempting to have carnal knowledge of a girl under thirteen years. He was imprisoned on March 24th, 1902; the trial was on May 30th, and he was removed to the asylum on July 1st, symptoms of certifiable insanity having been first observed by the medical officer to the prison on June 26th. The total term of imprisonment was therefore rather over three months.

The attention of the Council having been called to a statement that errors existed in the Statistical Tables prepared by the late Tuberculosis Committee, the Council inquired into the subject, and finding, as a matter of fact, that such errors did exist, decided to place the Tables in question in the hands of a statistical expert for detailed examination and Report. Dr. Chapman, late Medical Superintendent of Hereford City and County Asylum, whose reputation as a statistician is well known, most kindly, at the request of the Council, undertook the work, and the Council feels that the Association is greatly indebted to Dr. Chapman for so freely placing his talents and time at its disposal.

A Large amount of both experimental and clinical work has now accumulated around this subject. I need only briefly mention the main results of the former, as they have been so often referred to by others that they are now probably familiar to all workers in this field.

I have ventured to suggest that we should now consider what we are going to do about the classification of mental disorders. Lately, the Royal College of Physicians of London decided to revise the Nomenclature of Diseases, and publish another edition. The President of this College is on the Committee; as is also Dr. Savage, our colleague in London, who has taken much interest in this question. I was somewhat surprised the other day when I asked for a copy of the Nomenclature of Diseases in the Royal Medical Society of London, to find that they did not have a copy in their library—a book which is supposed to guide the profession in the statistical registration of diseases. In 1896, for the third edition, an attempt was made to reform the nomenclature of mental diseases, under the direction of Dr. Hack Tuke and Dr. Savage. In its present state it is still unsatisfactory. The classification with which we have to deal is as follows:—First, there is “idiocy (cretinism), and then mania (acute or chronic), delirious, hysterical, puerperal, epileptic, traumatic, syphilitic, gouty, from either acute or chronic disease, alcoholic, plumbic, or other poisons.” Acute is an absurd word, because we specially want to mark the duration. Acute should be rendered Recent. Then there is “melancholia (acute or chronic), delirious, hypochondriac, climacteric, puerperal, epileptic, syphilitic, acute, other diseases.” Then there is “dementia (primary or secondary), senile, climacteric, puerperal, epileptic, traumatic, syphilitic, acute, other diseases.” Then there is “mental stupor, anergic, delusional.” Then there is “general paralysis.” That is not a mental disease. Lastly, there is “delusional insanity.”

The following observations were made by my assistant (Dr. Peebles) and myself with the object of observing the physical symptoms of katatonia and hebephrenia. As the result of these observations we were led to make some experiments in the way of treatment, and we combined with this work some experimental observations on rabbits.

The feature of Jacksonian epilepsy to which I wish to call attention is the periodicity of the discharge. Whether we regard the lesion as “irritative” or “discharging,” it is, at all events, chronic; and whether we regard the discharges as going direct from the cortex to the efferent nerve-cells, or as causing convulsions in a more roundabout way through subcortical systems, they are, at all events periodic. How, then, do chronic lesions cause periodic discharges ? The answer which I wish to put forward is suggested by certain passages in Mercier's Psychology, Normal and Morbid, p. 283, which run as follows: —Speaking of how organic bodies may contain a store of motion which can be liberated by the impress of motion from without, and after likening this property to that of animals and their power of movement, the author continues, “But animal organisms have a further property which most inorganic bodies have not. They are continually adding to their stores of motion, and by these continual additions their store at length becomes surcharged. The tension of the contained motion reaches such a pitch that the containing resistance is no longer sufficient to keep it in bond, and it breaks out, possibly without the provocation of added motion, certainly with minimal provocation.’’ Later on, when discussing “Will and Desire,” the same author writes of nervous mechanisms, “There are many machines used in the arts, which depend for their actuation on the gradual filling of a vessel with water. The vessel is of such a shape and so supported that, as it fills, the centre of gravity shifts, until, at a certain degree of fulness, the vertical at the centre of gravity falls without the base; the vessel then capsizes, empties its contents, regains its previous distribution of weights, rights itself, and begins to fill once more.”

My paper to-day is the natural outcome of the address by Sir William Gowers upon “Sanity and Insanity, Lunacy and Law, the Views of a London Hospital Physician, particularly in regard to Private Patients,” given at our last general meeting in London. The discussion which followed was hardly worthy of the subject. Most of the earlier speakers, although eminent general physicians, had had little or no experience in the care and treatment of the insane; therefore, when the turn came for those practically acquainted with mental diseases to speak, the hour was advanced, the audience was weary, and an all too exacting brevity resulted.

The question of utilising female nursing to a greater extent than formerly in the care of male patients in asylums has roused much interest of late years, and has been brought under the consideration of the Association on several occasions. In advocating the adoption of this form of nursing one is apt to give the impression that the method is something entirely new as applied to asylum patients. But that is not intended, for in reality the system has existed to some degree for a long time; and it is only the question of the advantages of extending it, and making it much more systematic and complete, that is now raised. In some places on the Continent it has been in use for a number of years, and is developed to a greater extent than is usual in this country. In April last I had an opportunity, in company with Sir John Sibbald, formerly Commissioner in Lunacy for Scotland, Dr. Fraser, Commissioner in Lunacy for Scotland, and Dr. Robertson, medical superintendent of the Stirling District Asylum, of visiting two institutions in Holland and seeing the method in practice; and I now venture to submit some notes, not by any means exhaustive, of what was observed there, and to make these, and my own further experience of the system at the Fife Asylum since 1896, when I had the privilege of reading a paper descriptive of it at the annual meeting of the Association, the basis of my remarks at this time.

Following up my observations made upon the blood of patients suffering from acute continuous mania read before this Association at the autumn meeting, I have been able to observe three cases of acute continuous mania in adults which relapsed while in the asylum. The results of the first series of observations were that in every case of acute continuous mania there existed a leucocytosis which persisted after recovery indefinitely. I advanced the theory that this leucocytosis was a protective leucocytosis. In the three patients who relapsed the leucocytosis was found to have fallen to below 13,000 per c.mm. of blood, instead of being nearer 20,000 per c.mm. of blood, which is characteristic of the recovered cases of mania. The polymorphonuclear leucocytes averaged 60 per cent, in two of these patients, and 47 per cent, in the third. In one of these patients the attack passed off in two days, and the leucocytosis at once rose to 25,000 per c.mm. of blood. The other two patients passed into a definite second attack, and their leucocytes averaged 15,000 to 16,000 per c.mm. of blood, with a polymorphonuclear percentage of 60 or below 60. The fact that the leucocytosis fell in each patient at the commencement of the attack, and rose at once in the patient who recovered from the relapse, strengthens the hypothesis that acute continuous mania is an infective disorder, and that immunity from maniacal attacks rests upon the resistive power of the individual patient. This hypothesis receives further support from the fact that there exists in the blood of patients suffering from acute mania a specific agglutinin. During the month of November a patient suffering from acute mania was admitted to Murthly. The patient was so ill that I did not think she would live many days. I isolated from the blood a very small coccus, which was a pure growth, but, as the patient was exhausted, I regarded the organism as a terminal infection. The patient improved, however, and three weeks later I tested the agglutinative power of her serum upon this organism in a dilution of 1 in 30. Agglutination was complete in three hours, while the serum of a member of the staff in a dilution of 1 in 20 produced no action in twenty hours. Since then I have made fifty agglutination tests with this organism. Only ten of these cases, however, have been pure cases of continuous mania. Eight gave a decided definite agglutination, one was doubtful, and the tenth—one of the patients above noted, who relapsed—gave no reaction. No “control” serum ever gave a reaction, nor did the serum of these patients suffering from mania agglutinate other organisms. The agglutinin in the blood was therefore a specific agglutinin.

There has been a considerable amount of attention called to the subject of phthisis in asylums lately, and since the publication of the report of the Tuberculosis Committee the subject has appeared in a broader light. Although much is being and has been done for the prevention of phthisis by means of the Sanatorium movement, and the varieties of the technique of hygiene which are included in that treatment, yet there are still many aspects of the disease (both in the sane and insane) which require precise investigation, such as the variations in the composition of the secretions and excretions when the body is in the state of phthisical toxæmia; the relationship of the tuberculous toxæmia to other toxæmias, such as the influenzal (27), gouty, etc.; the accumulation of toxins, and its relations to recurrent forms of disease. The number of deaths from tubercle here during the past year we find to be ten; in 1900 it was nine, and 1899 it was fifteen, so that from a percentage of 1.3 in 1899 it has dropped to 0'85 in 1901. On examining the position of this asylum in the tables drawn up by the Tuberculosis Committee (1) we find it tenth in the asylums in England and Wales which are classified under Division i, which asylums have a tubercular death-rate of from 0.5 to 2.2, the county asylum at Exminster having a percentage of 1.3. This compares favourably with other asylums, some in the Division 2 having a tubercular death-rate of 5.1 and 8 per cent. respectively.

It augurs well for the success of the action taken by the Conjoint Committee of the British Medical Association and this Association with regard to the amendment of the Lunacy Law, to enable cases of recent (incipient) insanity to be legally treated in private care, without being certified as lunatics, that the Lord Chancellor inserted into his proposed Lunacy Bill a clause to meet our requirements, in the very terms I advocated at the annual meeting of the British Medical Association in 1896.

This remarkable case of double consciousness was under my constant observation for about four years.

Gentlemen,—It is now some eight years since I had the pleasure of receiving the South-Western Branch at this Institution, and I take this opportunity of expressing the pleasure it gives me to see you here to-day.