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.

The symptoms dealt with in psychological medicine are largely those of faulty adaptation to environment. Certification has as its basis abnormal reaction to stimuli requiring the more complicated responses of the organism. For many years pathological investigation of the psychoses was chiefly confined to post-mortem examination of the brain, but the activity of the brain is dependent on the functioning of the rest of the body, and of recent years research has been conducted on a wider basis.

During the course of the last few years the study of the cerebrospinal fluid in both mental and nervous disorders has made rapid progress, and with the introduction of methods of precision much useful knowledge in regard to its physical, chemical, and serological properties has been acquired. Nevertheless, much remains to be learnt, and we propose to submit observations on one aspect of the subject which is still in its infancy, namely, the pressure of the cerebrospinal fluid, and the modifications which it may undergo in the insane. At the outset, however, it will be convenient to refer in as few words as possible to the distribution and circulation of this fluid.

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.

Having been honoured by requests to describe my experiences in Lunacy in Egypt, and my services in Egypt having recently come to a close, I desire on the present occasion to offer to my fellow-workers in England a résumé of the changes in Egyptian Lunacy administration for which I have been responsible during the past 28 years. Detailed accounts of these changes have been printed annually in the Egyptian Lunacy Reports. I shall feel honoured if the Association will accept a copy of the Reports for its Library.

The following notes are derived from the case-records of the Royal Victoria Hospital, Belfast, by kind permission of the medical staff, and are placed before you on the suggestion of Col. Dawson. They are an analysis of a series of 42 cases of encephalitis lethargica treated as in-patients of the Hospital between October 5, 1918, when the first case was admitted, and December 31, 1923. Of these 42 patients, 14 died in hospital, and of 28 who survived 2 died within a year of leaving hospital; 18 replied either in person or by letter to my circular letter of inquiry, and I was unable to trace the remainder.

A preliminary note on the use of collosol bromine in the treatment of the insane epileptic was published in the Journal of Mental Science, July, 1923.

The history of the colloidal gold reaction is one of great interest. In 1901 Zsigmondy used the precipitation of colloidal gold by proteins as a means of determining quantitatively their amount in given solutions. He discovered that solutions of protein give protection to colloidal solutions of gold up to a certain point, and he determined the so-called goldzahl for various protein substances, by which is meant the number of milligrammes of protein employed, just sufficient to prevent the precipitation of 10 c.c. of colloidal gold of a percentage of .0053 in the presence of 1 c.c. of 10 per cent. sodium chloride. By this method it can be determined whether a given protein is absolutely pure, or, granted that this is the case, how much of the protein is present in a given solution.

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.

The relative rarity of cases of folie à deux provides the reason for the publication of these notes, together with a comparative simplicity of the mental mechanisms on the side of the passive agent.

An action seriously affecting the interests of the medical profession has been brought by Mr. William Smart Harnett, a farmer, of Springfield, Newington, near Sittingbourne, Kent, against Dr. Charles Hubert Bond, a Commissioner in Lunacy, and Dr. George Henry Adam, the manager of a house for the reception of lunatics at Mailing Place, West Mailing, Kent, and the hearing, including the argument on the jury's findings and the delivery of the judgment, before Mr. Justice Lush, in the King's Bench Division of the High Court of Justice, lasted from February 7 to 29—seventeen days in all. The action was for damages for alleged conspiracy, assault, and false imprisonment, and the jury on the fifteenth day returned a verdict in the plaintiff's favour, awarding a sum of $25,000 as damages. In the preparation of the following account we have made much use of the reports published in the Times.

Considerable interest has been shown of late in the occurrence of iron in the brain and its relation to certain nervous diseases. The existence of the iron can be demonstrated by placing a section of brain in concentrated ammonium hydrosulphide solution. After a few seconds the globus pallidus and the substantia nigra become a greenish-grey colour. Later, the red nucleus, the corpus dentatus cerebelli, the putamen and caudate nucleus also darken.

A great amount of literature has been contributed to the medical press in America, the continent of Europe and in this country about the action of luminal and its sodium derivative in preventing epileptic fits.

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 case was tried at the Central Criminal Court, on January 16, before Mr. Justice Greer. The prisoner was 37 years of age, and had been employed for four years, as a childrens' nurse, in a family living at Kensington. Two children were under her care, Sonia aged 4 years, and Jean aged 9 months. Until the birth of the second child the mother had been in the habit of going daily to business. As a consequence, the care of the elder child had, to an unusual degree, devolved upon the prisoner, who became exceedingly fond of the child. After the birth of the second child the mother was more at home. The prisoner appears to have resented this, and there were frequent disputes, culminating in a blow being given by the prisoner to her mistress. As a natural result, the prisoner was given notice to leave her situation. That same evening the prisoner's employers went out. On their return they found the nursery window closed and the door locked. Next morning the room was entered by the window. The child Sonia was lying dead upon the bed. The baby was lying unconscious, and died later. The prisoner was also in an unconscious state, and a gas-ring in the room was turned fully on. In the room was found a letter written by the prisoner, which said, “I am taking them both. I could not leave my Sonia to the creature she calls mother.” The prisoner had also written to a friend in these words, “I am taking my darling Sonia with me. I know she would not be happy here without me. I did not want to take Jean, but I could not put her outside.” The prisoner was removed to the Fulham Infirmary. After having been unconscious for six days, she recovered, and made a statement, in which she said that the children did not want her to go, so she said she would take them with her. She also stated that she remembered turning on the gas, and said that she wished she had been allowed to “finish” it.

Actinomycosis is a rare local specific infectious disease, due to the actinomyces, or ray fungus. The actinomyces is a streptothrix, and grows in colonies which are just visible to the naked eye, and these colonies, on microscopical examination, are found to consist of three elements–filaments, cocci, and clubs. In young cultures they stain uniformly, and are Gram-positive. The streptothrix gives rise to a hard, slow-growing tumour, going on to ulceration, with a thin sero-purulent discharge, containing yellow granules in which the ray fungus can be found. The organism is found growing on cereals, especially barley, and commonly infects cattle. Man is infected in the same way, and the disease is generally met with in farmers, corn-eaters, graziers, etc., especially if the patient has the habit of chewing straw, the infection most commonly occurring in the tongue, jaw, and spreading thence to the skin of the face and neck.

There being no law on lunacy in Egypt, all procedure is by administrative orders. The Government has the right to take any steps necessary to secure public order. There is no Habeas Corpus Statute in Egypt. The Criminal Code prohibits illegal sequestration, but if the sequestration is done by the Government with a proper motive, it is apparently justifiable legally. The existing public hospitals for the insane belong to the Central Government; the local municipalities and commissions have none. In the local general hospitals, however, under the Public Health Ministry, there are special rooms constructed for the temporary accommodation of insane persons awaiting certification, or too ill to travel. The Lunacy Division of the Ministry of the Interior administers the hospitals for the insane and issues the necessary orders, which are, however, signed by the Minister; it also proposes the annual budget, and expends the sums granted according to the regulations of the Ministry of Finance. Grants for buildings are made to the Public Works Department, which plans the buildings on the instructions of the Lunacy Division, arranges the contracts, and supervises construction. The Division is almost as autonomous as a Government Department can be; and subject to the technical regulations of the various Ministries and the approval of the Minister, can decide its own questions. The legal Counsellor of the Ministry of the Interior advises it in legal questions, and defends it when attacked in Court. For the present the Director of the Division also acts as Director of the chief hospital at Abbâsîya, but the arrangement should be altered on the passage of a Lunacy Act.