Originally used to describe any case of dementia with chronic excitement, the term “chronic mania” has been limited in its application to a group of cases described by Schott and others during this century. In the main, they apply it to cases of mania developed after the age of 40, and differing from an acute attack chiefly in their long duration. In the cases I describe I have confined myself to this usage, and have not included constitutional fluctuating hypomanics who have manifested this after their youth onwards, nor do I include prolonged manic phases in circular manic-depressive cases.

The case about to be described presented a problem of some complexity in neurological diagnosis. The attempt here made to unravel the problem is set forth with the full realization that some quite different explanation may be the true one. The true explanation, however, is incapable of proof and the view offered here is only suggestive, though of some interest because of the rarity of lesions of the superior cerebellar peduncle in man.

Written language is a complex function; being built on the spoken word it has to draw on a variety of subsidiary functions which have to be unified in one particular skill. Moreover, the subsidiary functions are not the same for reading and writing; in reading, visual-gnostic factors are of major importance, in writing, special skill of hand and finger is required.

The occurrence of irritability has been described in most text-books as a symptom in manic and depressive states. The causation of this symptom and the circumstances in which it is observed, have not received much close attention. Most authors put the states of irritability under the heading of mixed states. They cannot, however, be regarded as such in a strict sense, because the effect of irritability brings into the picture something new which cannot be derived from a mixture of the basal manic-depressive symptoms.

In Dr. Turner's paper on the classification of insanity in the January number of the Journal occurs this passage: “It is from cases of this class” (epileptic insanity, psychasthenia, morbid obsessions, and impulse) “that subtle dialecticians seek to prove there may be disorder of conduct without disorder of mind.” As I am the only person who has ever made any distinction between disorder of conduct and disorder of mind, or has ever said that the one may be disordered without disorder of the other, it is manifest that I am the subtle dialecticians referred to by Dr. Turner, and I must express to him my obligation for justifying me in the future use of the royal We. We must point out to him, however, that after the manner and habit of members of this Association, he attributes to Us views that We have never expressed and never held. We have, indeed, taught for many years, and iterated and reiterated, that disorder of mind may exist without disorder of conduct, and this view is again expressed in Our paper published in this Journal in October, 1910, but We have never expressed the opinion, subtle dialecticians though We may be, that disorder of conduct ever exists apart from disorder of mind. Perhaps Dr. Turner will be so good another time as to verify his references.

I submit the following suggestions in reference to the Decoration and Furnishing of Asylums in response to the appeal of Dr. Savage at last year's General Meeting of the Society—his request that members should take up subjects connected with the everyday practical details of asylum management. I trust that this may prove helpful, and that the limits imposed upon a single paper will not be meagre to baldness.

It is a very great honour to occupy the Presidential Chair of the Psychiatric Section of the Royal Society of Medicine; it is one which I appreciate most highly, and thank you warmly for.

A case of hydrocephalus, in many respects similar to the one described by Dr. Fred Wilson in the Journal of Mental Science for April, 1925, was also observed in the Asylum at Bangalore in December, 1924.

In St. Crispin Hospital, Northampton, there are male identical twins (J.L. and P.L.) who for nearly a quarter of a century have suffered from an atypical psychosis. They were previously studied by Palmer (3). Their sister (B.L.) had a similar mental illness but she obtained relief from a leucotomy operation at an early stage. The mother was also affected, but the onset of illness in her case was later in life. There are two unaffected siblings.

In deep coma the patient usually lies still, without moving. Why doesn't he move? Many will answer, “Because he is unconscious”. This is on the assumption, which seems eminently reasonable, that motor centres are under the control of a higher centre for mind. On voluntary movement, according to this assumption, motor centres receive and obey impulses from the psychic centre. When the psychic centre is paralysed, as in coma, the motor centres lie idle, like men in a factory marking time because the foreman is away and there is no one to tell them what to do.

At the outset it may be desirable to give a brief outline of the phenomena upon which this work is based.

A complete historical survey takes us back to very early times, to the days of Hippocrates and in more recent times to the humoral pathologists, when the formation of the “crust phiogistica” or “buffy coat” was practically the only blood symptom known. Until the old humoral theories were discarded, that is until the rise of the doctrines of cellular pathology, the problem loomed large, but after this period interest in it declined, until the whole matter was revived about ten years ago by R. Fahraeus, of Stockholm, who published a series of researches into what he termed the “suspension stability” of the blood. By this term is meant the power which the plasma has of holding the erythrocytes in suspension. When the stability is lowered, the corpuscles sink with increased rapidity. This author found that a lowered suspension stability occurred in a large number of morbid conditions, and also in one physiological condition, namely pregnancy. Since the publication of this work the phenomenon in question has been made the basis of a test which has found considerable application in certain departments of medicine, notably in gynæcology and tuberculosis.

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.