Numerous observations have lately been recorded in medical literature on the acute manifestations of epidemic encephalitis; but the late after-effects, especially those of a psychotic nature, have been seldom described. Kirby and Davis (1) have emphasized this, and have recorded 18 cases in their early and later stages. They remark that “a satisfactory solution of certain of the psychiatric problems presented by this disease will require a longer period for clinical observation of cases than has elapsed since the appearance of the epidemic of 1918–19.” The following series of 10 cases is offered as a contribution to the clinical records of the sequelae of the disease, especially from the psychiatric point of view. Eight of them originated in connection with the epidemic of 1918–20. The remaining two are of remoter origin, and are admitted on account of their close resemblance to the others, and of their special interest from the point of view of classification and prognosis. Five of them (3, 5, 6, 9 and 10) are, or have been, in mental hospitals. In this connection the only statistics available to me are those quoted by Kirby and Davis (loc. cit.) for the New York State Hospitals in the hospital year from July 1, 1919, to June 30, 1920, when, out of 6,500 admissions, only 20 were considered to be probably cases of epidemic encephalitis. (But the epidemic was subsiding at that time.) The 5 cases mentioned should therefore be of considerable interest; and it is one of the purposes of this paper to show that a more thorough knowledge of the results of this protean disease would lead to its being diagnosed more frequently among the cases, even those of very long residence, in mental hospitals.

The diagnosis of dysentery is a matter of considerable administrative importance in mental hospitals.

There is probably no disease in regard to which our views have undergone so radical a change during the past few years as general paralysis of the insane, and none in which the discovery of the causative agent has been followed by so rapid a revolution in standpoint. Although almost from the time of its definition, more than a century ago, the essentially organic nature of the disease and its close relationship to syphilis have been universally recognized, it has required many years of patient study to free it from the hypotheses which have been invoked to explain its obscurities, and, as always happens in scientific progress, in the process of unravelling the knotty problems of this disease, we discover that there are new obstacles and difficulties to be overcome. Is the Spirochóte pallida alone responsible for the genesis of general paralysis? When does it gain access to the nervous system, and how? Is there a special strain of spirochóte, or must the individual resistance of the infected person be considered the deciding factor in the development of the disease? What is the meaning of the long latent interval before the onset of symptoms? What determines the peculiar distribution of the lesions in general paralysis, and is there some particular place in the brain from which the spirochæte starts its wandering? What is the significance of the absence of spirochætes in other organs of the body, and why does the cerebro-spinal fluid contain no organisms at a time when the brain contains millions? Why do tabes, general paralysis and optic atrophy, supposedly of similar origin, not occur in conjunction more frequently? Why is it that arsenical compounds fail to effect a cure?

Metabolism means the chemical changes of materials under the influence of living cells, and basal metabolism as the rate of energy exchange during rest when only the essential vital processes of the body are at work.

It is a truism that successful treatment in any branch of medical practice, or, indeed, in a wider sense, in any activity in which we may be engaged, depends on an adequate and exact knowledge of the relation of cause and effect, and the conscientious clinician who bears that fact in mind finds the present position of clinical psychiatry one of great difficulty. As a highly esteemed physician remarked a little while ago—during one of those outbursts of professional candour which seem to be necessary at times in the interest of our self-respect, so far as our capacity to really modify the condition of our patients is concerned, we are in the position of interested observers, for we may arrange conditions, we may guard against added stresses, but do what we will, and however hard our endeavour, our patients alter, some to improve, others to deteriorate, with an aggravating indifference to our efforts. It behoves us, then, to be extremely critical of our assumptions in any particular case, to be as precise and as adequate as possible in our description of the whole train of events, and to review very carefully any deductions we may make as to the relation of possible cause and effect.

There is a Persian saying that there is no greater anguish known among mankind than to have many thoughts at heart and no power of deed. This particular form of anguish must be well known to most medical superintendents of mental hospitals, for how many of them long to be able to raise the standard of work at the hospital whose welfare they have at heart but, for some reason or another, the power of deed is denied them? Nevertheless, in spite of many a heart made sick by deferred hope, every medical superintendent is probably in a position to raise the efficiency of the hospital in his charge provided he can get plenty of good ideas to work with.

Ever since Wagner von Jauregg directed attention to the results of the treatment of general paralysis by various infective agencies, this matter has been the subject of active investigation in several centres. From a perusal of the literature it seems clear that the best results have been obtained from infection with benign tertian malaria. Moreover, this mode of treatment appears preferable to many others suggested, in view of the fact that it involves a minimum of risk in its application. Once a suitable malarial patient has been found, it is easy to inoculate many more from him, and the type of malaria which results can be controlled with great facility by means of quinine. An experiment of this sort has been in progress in the Royal Hospital at Morningside under the direction of Prof. George M. Robertson since March, 1922, and the results which have so far accrued are shown in the accompanying table. The method of inoculating the general paralytic and the details of the subsequent treatment need not be recapitulated here, as they are fully dealt with in the issue of the British Medical Journal dated October 20, 1923.

In the early part of 1922 our attention was drawn to the excellent results claimed by Wagner-Jauregg (1), Gerstmann (2), Weygandt (3) and others in the treatment of general paralysis by the inoculation of malaria. Since July 31, 1922, over fifty general paralytics have been subjected to this form of fever therapy, and in this contribution we propose to give a brief summary of our observations and com elusions.

Relapsing fever as a curative agent in paresis has been tried as far back as 1921, when several continental observers favourably commented on it. The close similarity between the two diseases in their causal agents and blood-serum reactions strongly commends the theory that the induction of a spirochótal fever in general paralysis might lead to the production of immune and anti-bodies in sufficient amount as to effect an amelioration in the symptoms, if not a complete arrest in the progress of this deadly malady.

It has long been known that remissions of varying degree and duration may occur in chronic mental states as a result of acute febrile intercurrent disease, and many attempts have been made to produce such an acute febrile reaction by artificial means, with a view to improving the mental condition thereby.

This Committee was constituted in July, 1922, by the Lord Chancellor, The Earl of Birkenhead, “to consider and report upon what changes, if any, are desirable in the existing law, practice and procedure relating to criminal trials in which the plea of insanity as a defence is raised, and whether any and, if so, what changes should be made in the existing law and practice in respect of cases falling within the provisions of Section 2, sub-section (4) of the Criminal Lunatics Act, 1884.”

This case was tried at the Central Criminal Court on November 20 before Judge Atherley-Jones. The defendant was charged with unlawfully attempting to forge a copy of the London Gazette. He had served as a lieutenant during the war, and on leaving the Army went to Cambridge University. He was convicted of theft in 1922. And he appears to have conceived the idea, partly in connection with this conviction, of forging a copy of an official publication, in order to bestow upon himself titles and awards of which he was not possessed, It was suggested that his object was to deceive his father and mother as to his military position.