Observations on psychoses associated with the influenza epidemic of 1918. The material is divided into two groups—(1) cases in which influenza was the direct cause of the psychosis, fever-delirium, and post-febrile amentia; (2) cases in which the toxic condition aroused a latent tendency to mental disorder. Naturally only the severest cases of delirium came under treatment in the clinic and fifteen are included in this study. The symptoms were confusion, terror, psycho-motor excitement, and delusions of persecution and poisoning associated with hallucinations. The majority of cases were men; the earliest onset was the second day of fever and the latest the eighth; the prognosis in respect to life was bad, 12 cases ending fatally, whilst the mental symptoms subsided with the fall of the temperature in the three cases which recovered. Post-febrile cases numbered 30, the greater portion of whom were women. The symptoms were association disturbances, confusion, and hallucinations, and the psychosis began with sleeplessness, fatigue, irritability and nocturnal hallucinations, some cases of short duration remaining at this stage. The prognosis was good, and no case ended fatally. The interval between the fall of temperature and the onset of mental symptoms varied from two to fourteen days. In no case was the influenza the sole factor in the production of the post-febrile psychoses. An hereditary factor could be excluded, but lactation, pregnancy, alcohol, or malnutrition appeared as subsidiary causes. In view of the relatively small number of psychoses in a widespread epidemic the writer concludes that there must be an unknown causal factor in these cases.

The author considers that pain and its analogues, malaise, discomfort, ill-being, etc., whether of functional or organic origin, being forms of sensation, are essentially mental phenomena arising in the brain, and can be removed by psychotherapy. That the mind can act upon the body and influence every function is a well-established fact. It is possible, too, that certain organic changes, vascular disease, heart disease, etc., may be traced to certain mental processes—anxiety—causing, excessive secretion by the adrenals. In every case of illness some of the symptoms are due to suggestion either from within or from without. This was seen in many of the “slow recoveries” in the war due to auto-suggestion. In organic disease psychotherapy cannot effect a cure, but in every case it can assist and give relief to suffering, e. g. pain in cancer. In earlier days suggestion was employed unconsciously in the use of charms, amulets, religious relics, etc., in later days in mind-cures and Christian Science. The relief of symptoms shows that faith alone is a potent curative agent, and that the majority of the ordinary symptoms are mental in nature and removable. The methods employed in psychotherapy are suggestion under hypnosis, suggestion in the waking state, persuasion and re-education, and psycho-analysis. In “superficial” cases immediate results often follow suggestion, but in the more chronic cases the removal of a symptom by suggestion is often followed by relapses, a new symptom taking the place of the rejected one, as the underlying condition of morbid suggestibility has not been removed. To overcome this condition Dubois introduced the method of persuasion. He thinks that an appeal should be made to the intellect by talks with the patient on the subject of his nervous symptoms. Persuasion is to some extent a form of suggestion, as in all degrees of belief feeling as well as the intellect is involved. Upon re-education largely rests the completeness of the cure; the connection between the mental antecedents and the symptoms are explained to the patient; when these are understood and acted upon his mal-adaptation ceases. Freud has shown that the patient may be most profoundly influenced by feelings and ideas of which he is quite unconscious. No persuasion avails until the unconscious motive of his mental or nervous symptoms has been uncovered. The process by which this can be done is known as psycho-analysis. Three methods of probing the unconscious mind are mentioned—the word-association test, the free association of ideas, and the analysis of dreams. Psycho-analysis has its limitations. It is not usually successful in curing persons above middle age; even when successful the treatment may take months. Robertson thinks that in many cases it is unnecessary. No successful physician who has not given attention to this subject has the faintest idea of the extent to which he employs psychotherapy unconsciously. Every practitioner and student of medicine must be taught the part the mind plays in the chief symptoms of disease, and he must consciously use psychotherapy in the treatment of these. His success will depend on the depth of his convictions.

The method employed consists of three stages: (1) The conversion of the total nitrogen into ammonia by the Kjeldahl process; (2) the conversion of the ammonia into pure aqueous solution; and (3) the calorimetric estimation of the ammonia in this solution by means of Nessler's solution. The result is expressed as “nitrogen number,” which denotes the number of hundredths of a milligramme in 1 c.c. of cerebro-spinal fluid. In general paralysis there is a high nitrogen number, which is marked towards the termination of the disease. It may be low in the early stages or in remissions. In mania the nitrogen number is always low—a factor of diagnostic importance in distinguishing between this disease and maniacal phases occurring in general paralysis. In imbecility, dementia præcox, paranoia, amentia and epilepsy the nitrogen number varies, but is usually low, and in terminal dementias it is very high. It was also found that density and nitrogen numbers run parallel to one another, with the exception of epilepsy, where high density obtains. The author emphasises the fact that choline does not occur in the cerebro-spinal fluid in mental diseases, and that ammonium salts only occur in the merest traces.

Hyperglycæmia is found in emotional states and may lead to temporary glycosuria even in normal persons, and it may exist with normal metabolism. It may be found in mental disorders with emotionalism and the mechanism of its production is by stimulation of the suprarenal glands causing hypersecretion of adrenalin, which circulates to the liver, where more glycogen is mobilised and in consequence more glycose is found in the peripheral blood. In this research Bang's modified method was used for the examination of the blood for glycose, and examinations were made before breakfast and $f34 hr., 1$f12 hrs., and 2$f14 hrs. after this meal which consisted of 100 grms. of bread and 200 c.c. of milk. In dementia præcox and epilepsy the blood sugar was found to be subnormal before and slightly above the normal after breakfast. In dementia paralytica and non-anxious melancholia the blood sugar was slightly above the normal before and considerably above the normal after breakfast; and in anxious melancholia the highest blood sugar content was found at all times. In amentia, anxious patients showed a great increase of blood sugar after breakfast as compared with non-anxious patients, and in mania a similar increase was present in real emotional states, but was absent in hypomaniacal forms in which the patient was only optimistic and cheerful.

The writer regards all convulsions accompanied by unconsciousness as symptoms of some underlying state or disease, and he believes that epilepsy is an organic condition due to definite pathologic cerebral tissue changes. Morbid conditions of the pituitary gland are found in a number of cases causing a change in its secretion. The investigation of 200 cases of epilepsy by roentgenographic examinations revealed some evidence of pituitary disturbance in 31·5 per cent. Some of these showed evidence of syphilis or other disorders and 14 per cent. were regarded as pure pituitary cases. From his observations the writer concludes that there is a definite relation between the undersecretion of the pituitary gland and a group of convulsive attacks usually termed epilepsy; that this group is divided into a chronic hypopituitary type and a transitional hypopituitary type by both clinical and roentgenographic evidence; and that pituitary gland feeding has a markedly beneficial effect, not infrequently leading to a cure.