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.

Many years ago—between 1854, when I was appointed to the medical charge of the Murray Royal Institution, and 1859, when the first Report of the new Lunacy Board for Scotland was issued—I took much interest in the subject of provision on the large scale for the chronic insane; advocating strongly for the harmless, incurable, industrious classes thereof, some modification of what is now variously known as the “Gheel system,” “Boarding-out system,” or “Family system,” of treatment. I was then of opinion that, hesides utilising or applying this system on the small scale in connexion with existing or prospective public hospitals for the insane—it was not only desirable, but feasible, to construct de novo one or more National Colonies on the Gheel plan—adopting of course only those features in the original Gheel that were worthy of imitation, or that it might be found practicable to imitate, in this country—and omitting or modifying those that appeared objectionable. I had no doubt as to the practicability of the scheme; though I was quite alive to the objections that would be offered—the difficulties that would attend its inauguration. Most unfortunately, as it seems to me, such a plan did not at that time, in any form, find favour with the authorities charged with the control of the state arrangements for the treatment of the insane poor in Scotland, and a golden opportunity was thus lost of establishing on Scottish soil an improved Gheel free ab initio from the defects of its grand prototype.

Before narrating the case which is the basis of this communication, I shall briefly advert to the leading features, and the views held regarding the nature of the remarkable neurosis with whose discovery the name of the late eminent Dublin Professor, Dr. Graves, is most frequently associated. The dependence of the psychical and somatic phenomena on one cause, common to both, will thus be more clearly demonstrated, and the claim which it seems to me the disorder of the mind has to be regarded as a distinct form of insanity will be more apparent.

Treatments for enuresis have been legion, but several authors have recorded beneficial results from the use of ephedrine hydrochloride.

Since experimental observation has established the fact that inflammation of the central nervous system is easily induced by infection of the ascending lymph stream of nerves, it would seem that the views regarding the ætiology of inflammatory lesions of the cerebro-spinal axis must undergo considerable revision, and that an insufficient degree of importance has so far been attributed to the rôle and wide-reaching results of lymphogenous infection. That the spinal cord and brain are exposed to infection along this path cannot be doubted. This view is based upon both clinical and experimental data; and its value in connection with the elucidation of the ætiology of some nervous lesions may now receive more recognition, seeing that the range of application of the hæmatogenous theory is becoming more limited. To take one example: acute anterior poliomyelitis is no longer regarded by neurologists as a hæmatogenous infection of the spinal cord, with a special selectivity for the motor nuclei. Recent work shows conclusively that the inflammatory phenomena can only be the result of a lymphogenous infection.

When we pass under review the theoretical concepts of aggression three main types stand out clearly, which are fairly representative of prevalent opinions.