Delivered by Mr. Justice McCardie at the Quarterly Meeting of the Royal Medico-Psychological Association, November 20, 1930.

I have been asked by the President to open a discussion on out-patient clinics for mental disorders. Although these have existed for many years in some places, it is believed that they ought to be more general, and that one or more should be connected with every mental hospital. Their establishment has now become an urgent duty in view of the passing of the Mental Treatment Act.

Sterols, such as cholesterol, phytosterol, etc., are present in all animal and vegetable tissues, and play a most important rôle in physiological and pathological processes. For example, it is well known that cholesterol has a powerful influence in aiding complement fixation in sero-diagnosis—it checks the action of lipolytic enzymes and inhibits the hæmolytic action of saponins and cobra venom on erythrocytes. It is an important factor in giving cells their power of holding large quantities of water without losing their peculiar semi-fluid characters and without dissolving. Citron (1) states that 1 c.c. of an emulsion of central nervous system neutralizes three times the fatal dose for mice of botulism toxin and that lecithin and cholesterol act similarly.

In a very large number of cases of non-syphilitic mental disorder examination of the upper alimentary and respiratory tracts has shown the presence of diseased conditions of septic origin affecting the teeth and their sockets, the gums, the tonsils and the mucosæ of the mouth, pharynx, nasal passages, nasal sinuses and ears, including the diverticula contained in the mastoid.

Certain findings in the course of routine biochemical investigations at this Hospital suggested to us that the glucose tolerance test in epilepsy might show interesting results, and accordingly a series of 66 cases was submitted to this examination.

The cases of general paralysis here submitted, fifty in number, have all been treated by tryparsamide either alone or combined with a non-specific form of treatment. Some of them have been undergoing treatment since 1923, and consequently the method adopted has varied as the result of observation and experimentation. All of them have been under observation for at least two years.

The electrometric titration method for the investigation of “organic acids,” as developed by Perlzweig and Delrue (1) and applied to the examination of sera, indicated a method of investigation of the organic acids of the cerebro-spinal fluid, and an attempt has been made in this paper to investigate the significance of the organic acid titration in mental disorders. Owing to the difficulty of obtaining normal cerebro-spinal fluid, the research had to be confined to the investigation of paretic and non-paretic cerebro-spinal fluids obtained from mental cases. In the former case adequate specimens were obtainable during the process of collection of fluid for diagnostic purposes, and the results obtained in some cases were confirmed by independent collection.

Bleuler, in his Text-book of Psychiatry, says that “Reactive mania is unknown.” This statement occurs in the section devoted to the consideration of the reactive states; temporary psychoses, that is to say, where the ætiology is so clear and in such temporal contiguity to the onset of the symptoms that the illness can be definitely laid at the door of some recent alterationin the patient's total life situation.

The rôle of focal sepsis as a causative factor in mental disease has received increasing attention during the past few years since Cotton published his results in this field of inquiry (Journal of Mental Science, October, 1923). In England, prominent workers in this branch of medicine, while unable to report the striking therapeutic results of Cotton, have confirmed his main contention that many acute and subacute psychoses seem to be intimately related to some focus of sepsis. Thus confirmation of this main thesis has come from Graves (Journ. Ment. Sci., October, 1923 and 1925), Chalmers Watson (ibid., October, 1923), Hunter and Moynihan (Brit. Med. Journ., November 5, 1927). On the other hand, equally prominent psychiatrists have called in question the results claimed, and the alleged “proven relationship” of sepsis and mental disorder, chief among whom are Henderson and Menzies (Brit. Med. Journ., November 5, 1927, p. 818).

Psychiatrists and psycho-pathologists, on the whole, have never been subject to the error of thinking that a man is a unit whose reaction to a given stimulus does not vary. Their work in the clinic and hospital would quickly force them to give up any such supposition. They naturally look for the conditions under which fluctuations occur and would probably be interested to hear that there are rhythmic changes in man's emotion apparently characteristic of the individual himself. Whether such cycles can be traced to specific factors and principles may be a difficult task to determine. The mere fact of its existence may be of value in making the economist and manager of work mindful of individual factors, as well as of the many impersonal factors in the important question of emotional attitude toward work.

Richard Jeffreys, in one of his fascinating books, tells us he has often met with those who spend half their lives wishing for to-morrow and the other half wishing for yesterday. I thank God I do not come under this category. I love to look back at many of my “Yesterdays,” although, as with most of us, some of these have been overshadowed by dark clouds, but, by an inherited determination and an inborn optimism, I have, I am thankful to say, been able “to push dem clouds away” and once more the sun has shone brightly. As to my “To-days,” I do my best to get every ounce of happiness out of them, and as I believe in the philosophic teaching that happiness is infective, so my life is made the brighter by the hope that, being cheerful myself, I may be able to brighten the lives of some I have to associate with or work for. As to my “Tomorrows,” I am afraid I have never given much thought to these, being content to leave them in the hands of what I hope is a kind Providence, and I trust I have little to fear.

The social aspects of psychiatric work are assuming more importance, and it is being recognized that the work of an out-patient department for psychiatric cases is greatly facilitated and enhanced by the co-operation of social service workers, who have made a study of the economic and environmental conditions of the family.

The question of the prevalence of the Sonne bacillus as the causative organism in outbreaks of diarrhóa in mental hospitals in this country was referred to the Infectious Diseases Sub-Committee by the Research and Clinical Committee of the Royal Medico-Psychological Association. At a meeting of the Sub-Committee the subject was discussed, and it was decided to send out a form, asking for information, to those mental hospitals which are engaged in active bacteriological work. Each hospital was asked to state whether any case of diarrhoea due to the Sonne bacillus had occurred during the past five years.