This discussion was arranged by permission of the President to afford members the opportunity of considering certain points raised relating to the diagnosis, pathology and treatment of general paralysis in papers read by Dr. J. Brander and Dr. J. F. Smyth at the Annual Meeting on July 13, 1928.

When I first began the study of mental disorders, I realized that patients were, apart from their mental disorder, physically ill, and I was attracted to a study of the circulatory disturbances in these cases. This led me to consider whether these general circulatory disturbances were responsible for the mental state, in the same way that intracranial circulatory disturbances were in surgical brain cases showing mental symptoms. Examination almost invariably revealed weakness of the heart's action, irregularity of the pulse, low or high blood-pressure, and disturbances of the peripheral circulation. It was thus conceivable that disturbance of blood composition and supply might cause disturbance of oxidation in the brain and that many of these abnormal circulatory manifestations might be responsible for the production of mental disturbances. A study of various physiological and biochemical observations suggested that possibly there was in these cases some deficiency of essential salts, such as calcium. This led me to the treatment of mental disorders by the administration of salts of calcium—choosing calcium lactate. Fortunately I found at that time (1919) a very remarkable case showing severe mental symptoms and unusual circulatory disturbances.

Some few years ago, when the Annual Meeting of this Association was held at York, I had the temerity to inflict upon it a paper dealing with the subject of mental defect. Whether one derives a certain subconscious sense of security in speaking on one's native heath I hardly dare speculate. Whether, on the other hand, the circumstance of propinquity, as it were, to one's roof-tree stirs and stimulates that spark of local patriotism which lies latent in the humblest I leave to the conjecture of those of my hearers who may be psycho-analytically minded and sufficiently interested.

It has often been suggested that functional diseases of the nervous system are caused by intestinal toxæmia, and this suggestion has been revived by certain recent work.

Buscaino (1923–26)has described lesions of the small intestine in mental patients which result in undue permeability of its walls. He also describes a toxic substance in the urine in acute confusional and alcoholic insanity and in dementia præcox. This substance is brought down as a black precipitate by silver nitrate in the cold. The liver is deranged in these cases, and decarboxylates amino-acids presented to it instead of deaminizing them.

It is well known that the mentally defective population suffers much more from the ravages of tuberculosis in its various forms than does the normal population. In the annual returns of various institutions for defectives, and from a study of the causes of death of imbeciles as reported to the Board of Control, it would appear that tuberculosis kills four times as great a proportion of aments as of normal people. Tredgold (1) gives an analysis of 1000 consecutive deaths occurring in the Earlswood Institution, of which 413 were due to tuberculosis.

Many methods have been devised as adjuncts to clinical observation in the diagnosis of pulmonary tuberculosis. Leaving aside the use of the Röntgen rays and the method of cyto-diagnosis which at one time had vogue in France, the procedures may be divided into two groups: (1) those which depend on the observation of the effects of various extracts of the tubercle bacillus upon the patient; and (2) those which depend on laboratory observations upon various materials (sputum, blood, fæces, etc.). Among those in the former group are the tuberculin test, the Von Pirquet, Moro's cutaneous and Calmette's ophthalmic reactions. Their uses are limited. It is the methods in the latter group that lend themselves more readily to general use.

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.

The fact that seizures indistinguishable from those of “idiopathic” epilepsy occur in a considerable number of nervous and other physical disorders has compelled us to regard this discharge of psycho-physical energy as a symptom only, and the treatment should therefore vary from case to case in accordance with the particular pathological causation. The majority of cases that one has to treat in a mental hospital are of the idiopathic type, and the treatment is often unfortunately of a uniform empirical nature. Within recent years, however, there has been a tendency to develop some definite conception of the perverted physiology of the disease and to exhibit treatment accordingly.

In this hospital we have a routine differential diagnosis which is applied in all cases of suspected epilepsy and which is as follows:

1. (a) High blood-pressure.

2. (b) Trauma of vessels and angiospasm.

3. (c) Nephritis, subacute and chronic.

4. (d) Diabetes.

5. (e) Tabes dorsalis, tabo-paresis, neuro-syphilis and general paralysis.

6. (f) Hysteria.

7. (g) Epilepsy.

The scope of this work is to show the variations in blood-pressure and pulse, together with the secretory and vaso-motor changes, resulting from injections of adrenaline and pilocarpine. The response of certain reflexes is also recorded.

It is a matter of common observation that dementia præcox, in common with many other forms of dementia, pursues a very chronic course. In fact, the slow progress of the process is one of its outstanding features. In most cases of dementia præcox, no matter how sudden and acute the onset may be, the tendency is for this to subside after a varying period of time.