Experience of neurotic patients seeking treatment convinces me that paranoia is by no means so rare a disease as asylum statistics would lead one to suppose. For the purposes of the latter, of course, only fully developed and alienated cases are taken into account. Of the four cases to be discussed here, only one has said or done anything that could be recorded in a certificate, and the delusional picture was only unfolded at the patient's goodwill. None of these cases therefore would figure in statistics, yet all four are drawn in a short space of time from a limited section of the community. Paranoid trends, episodes or systems are, I believe, quite common in intelligent, cultured and well-developed minds, and account for a substantial amount of insufficiency and unhappiness. Apart, therefore, from the question of the treatment of the delusional asylum patient, the projected mental clinics will find themselves faced with a formidable problem in regard to the treatment of paranoid conditions. It is from the incipient and partial cases of paranoia that we can gain an insight into the factors which arrest or promote the disease. Only in the most exceptional cases does the fully developed paranoiac admit us within the circle of his fortifications.

At the outset of this communication let it be said that the intention is not to make any new or original contribution to the subject, but to re-state some old facts which, it seems to me, are in danger of being forgotten by the older ones amongst us, and have not been sufficently impressed upon those who have recently come to the study of general paralysis. My own experience leads me to hold suspect the way the diagnosis of this disease is arrived at to-day in many quarters, and consequently to question the validity of many published statistics. In the time at my disposal it is not possible to alter settled beliefs, but I hope to arouse doubts and to shake some confident and easy convictions. If the doubts be carried into the study of future cases my object will have been attained.

Hitherto the treatment of post-encephalitis has been profoundly unsatisfactory, and for the most part only palliative.

There are at present in mental hospitals some 200 cases; this is only a fraction of those not certified, and consists of an asocial class impossible to deal with outside a mental hospital.

The structures which separate the blood from the cerebro-spinal fluid are of considerable importance in the physiology and patho logy of the brain, since they form a barrier which allows only certain substances to diffuse from the blood into the cerebro-spinal fluid. It has been found that the acute phases of certain mental and nervous diseases are associated with an alteration of the permeability of the brain membranes which form this barrier. Only recently, however, has there been any quantitative investigation of the relative dis tribution of substances in the blood and cerebro-spinal fluid; by means of this quantitative ratio the degree of deviation from the normal in various conditions of disease can be readily determined.

Volvulus is not a very common condition. In large general hospitals the incidence is about one case or two cases a year. It has occurred here at Prestwich eleven times from 1923 to 1927, and comparing the huge population served by a general hospital with the number resident in a mental hospital the frequency of the condition is out of all proportion. This fact is the reason for the present paper, giving some account of the condition and stating the factors that were present in the cases. Whether certain types of mental cases are liable to develop this pathological state is a matter which will be discussed, and about which the experience of others will be welcome.

The rationale of the malarial treatment of general paralysis has not, so far, been thoroughly understood. It has been believed by some that the remission is due to the destruction of spirochætes in the cortex by the intermittent waves of high temperature, which leave them no time to organize a defensive mechanism. This explanation assumes that the destruction of the spirochæte with, perhaps, its removal from the brain may result in a cessation of the active progress of the disease and, in some cases, in a complete return to normal cerebral function.

It is now nearly sixty years since Langdon-Down first distin guished the mongol, and it must be admitted that to-day the ætiology of this type of idiot is as obscure as ever.

In a previous paper (Journ. Ment. Sci., April, 1928, p. 269) the writer has pointed out that a culture tube of tyrosine bouillon, if inoculated from the fæces of a healthy person, incubated for forty-eight hours and distilled, will be found to contain not more than 0.008% of phenol, or at most 0.015%. If, on the other hand, similar cultures are made from mental patients they will contain 0.02 to 0.03% of phenol in one half of the persons examined. In all these cases the phenol is formed by the action of bacteria on the tyrosine in an alkaline medium. The most important phenol-producing bacterium in the insane is B. Morgani, which can be demonstrated in 25% of acute cases, while B. phenologenes, Berthelot, is found in a smaller number. The paper referred to dealt with the toxic effects of B. Morgani and the results of vaccination with this organism. In the present paper another aspect of the matter will be considered, namely, the production of tyramine from tyrosine by intestinal bacteria, and whether poisoning by this substance may be a cause of mental disturbance.

This paper is a preliminary account of some investigations being carried out at this hospital in regard to the possible toxicity of medinal and other hypnotic drugs, and its relationship with aceto nuria and alteration of the ammonia coefficient of the urine.

The following is the first of a series of communications relating to urinary excretion in cases of mental disorder with special reference to acid excretion. In this paper it is proposed only to deal with the make-up of urinary acidity and the methods for the determination of the acid characters. It is well known that respiratory regulation constitutes the first line of defence against change of body reaction, and that the kidneys afford the second protection against alteration by variations in the acid-base ratio of the urine. It is also fully established that urinary acidity is dependent on the nature of diet ingested, but it is not so well recognized that the urinary reaction is also dependent on the adequacy of the respiratory compensatory mechanism, and it would appear that those interested in dietetics and chemical effects on urinary acidity have not appreciated sufficiently the significance of the physiological influences, and those concerned with the respiratory side have been apt to disregard the influence of diet. The organism promptly defends itself against alkalinity by the excretion of bicarbonate, whether the alkalinity be due to ingested alkali or excessive exhalation of acid (CO2), and this excretion of bicarbonate appears to be independent of any particular renal threshold for bicarbonate. The response of the organism to acidity, however, is a much longer process, and in this case the kidney compensation takes the form of retention of base by ammonium base production and the retention of bicarbonate by alteration of the ratio of mono- and dibasic phosphate excreted according to the equation—

I must crave your indulgence for this ambitious title to a very short communication. My aim is to stimulate a discussion and to probe the experiences of others.

It is well known that injection of protein substance into the blood causes the appearance in the blood of antibodies to the protein. Injection of bacteria is followed by the appearance of several kinds of antibodies, and the substances which produce “clumping” constitute one, or rather two, of these antibodies. The appearance of agglutinins in the blood following vaccination or infection has been shown to occur regularly in such a large number of individuals, and in animals, that there can be no doubt that this production of antibodies is a natural phenomenon connected with successful resistance to the deleterious effects of the organisms. Non-production or abnormalities in the production of agglutinins following injection of bacteria represents a pathological process probably of the nature of sepsis.

In a previous communication it has been shown that among intestinal bacteria of the coliform group Bacillus paracoli and Bacterium coli mutabile are at least four times more common in the insane than in the general community, and that they are to be found in great number in at least one-half of the former during acute phases of illness. It was suggested that both the illness and the increase of these bacteria might be due to a third factor, namely, to the action of some other intestinal organism, since certain workers had found that colon bacilli when grown on phenol varied to the mutabile type, and it is well known that phenol is formed in the intestine by certain bacteria.

Wakefield Mental Hospital was opened in the year 1818. Within a few days there appear in the case-books notes describing patients suffering from diarrhœa with blood and mucus. During the years 1818 to 1910 these or similar notes appear with such monotonous regularity that it would lead an outsider to believe that dysentery and its allied diseases were natural or at least unpreventable in asylums.

Epidemic encephalitis has become an increasingly important cause of insanity among the population, and during the past few years this disease has been seen more and more among the new admissions of mental hospitals. The various forms in which this disease may manifest itself in the chronic stage are now well known, and can be intimately studied in any large institution. Up till the present, however, no account has yet been reported, so far as I am aware, of the appearance of encephalitis lethargica among patients already resident in a mental hospital.

In the normal subject the reaction of the urine denotes the tendency to reaction change of the blood and organism—a tendency which is adjusted by the respiratory mechanisms. To maintain a constant blood pH and CO2/NaHCO3, the kidney retains or rejects base and the lungs increase or decrease acid (C02) output, these compensatory processes being interdependent. With a definite relationship between urinary acidity, blood alkali reserve and alveolar air CO2 tension the ratios are maintained. Urinary reaction represents the acid or alkaline “pressure”on the organism. The reaction of the blood and tissues depends on the adequacy of respiratory adjustment: in fact, as Henderson says, “low pH (acidity) in a fluid buffered like blood can never be due immediately to any other cause than relatively depressed breathing.”

Cardiac infarction follows disease or occlusion of the coronary arteries. In 90% of cases it is due to atheroma with final occlusion by thrombosis; embolism accounts for the remainder. The records of the last one hundred post-mortem examinations on patients over forty-five years of age at the City Mental Hospital, Leicester, indicate that marked coronary sclerosis or atheroma with more or less occlusion occurred in 23 cases—II males and 12 females. In 5 the occlusion was almost complete, with fibroid degeneration of the myocardium, whilst in 2 cases, those to be described, occlusion was complete and followed by infarction.

The preceding studies on the acid-base equilibrium in psychotics have made it evident that the failure to adjust must be attributed in the first instance to an inadequacy of the respiratory compensatory mechanism, and can be in no sense attributable to either a deficiency in the buffering power of the blood itself or to an increased organic acid production (acidosis). We have endeavoured to determine the excitability of the respiratory centre to the stimulus created by CO2. For this purpose a number of psychotic patients were tested as to the excitability of the respiratory centre to air containing 2% CO2 and the reaction compared with that obtaining in a number of normal subjects.