It is usual to open a paper with a historical survey of the subject under review. In a sense that is an academic approach. This paper, however, deals with the purely utilitarian aspect of psychiatric out-patient clinics; and a historical survey would only be in place if it were to give us practical suggestions, likely to prove of value in present circumstances. Up to the present time most of the literature of this subject has been in the shape of formal annual reports. A notable exception to this general statement was the paper on “The Oxford Clinic,” communicated by Dr. Good at the Annual Meeting of this Association in 1921. That paper was not only an account of the general method of working a clinic, but was a concise description of how psychiatric out-patients should be handled. It was followed in 1922 by a paper by Dr. Ninian Bruce, dealing more particularly with Ministry of Pensions Clinics, and expressing the view that the methods employed there could be satisfactorily adapted for civilian patients. It is interesting to note that Dr. Ninian Bruce used the future tense in describing the utility of these clinics, and that practically all of his forecasts either have come, or are coming, true. The methods described by these writers have been widely used in many clinics in the ten years which have since passed; various practical points have cropped up; legislation has been changed; and a review of the utility of the psychiatric out-patient clinic in the light of these things is the aim of the present paper.

For many years psychiatrists have appreciated the clinical value of the Wassermann reaction, not only in diseases of the central nervous system, but in somatic infection in the psychotic and the mentally defective. As a diagnostic test for syphilis, reliance has been placed on this reaction out of proportion, perhaps, to its relative efficiency; sometimes without a full appreciation of the difficulties which the pathologist has to face in rendering the test as accurate as possible, and also of the fact that the results must be interpreted both on clinical and serological grounds. Adding to the difficulties of co-operation between the two groups of observers, there has been the fact that, owing to increased efficiency in anti-syphilitic treatment during the past twenty years, the strength of the reactions to be found serologically has become progressively less marked. Thus, it is inevitable that many of the methods employed hitherto, although at one time satisfactory and reliable, cannot now completely fulfil all the criteria of a reliable test so essential to accurate diagnosis and the control of modern methods of treatment. Further, and of even more importance from the point of view of research and of the necessity of making strict comparison of the results of one laboratory with another, it has been ascertained that very little uniformity of method exists. This lack of cohesion not only reflects upon the efficiency of the routine work and research in mental hospitals, but isolates them as a whole from the Ministry of Health venereal disease centres, in that in very many instances the methods employed could not be strictly compared. From these facts alone it will be seen that sooner or later the time was bound to come when all the requirements of a standard method should be investigated and, from among many excellent techniques, the difficult task be faced of choosing one or a combination of tests that would serve the needs of the clinician and serologist working in the domain of psychiatry. At the time of the inception of the Pathological, Bacteriological and Bio-Chemical Sub-Committee there was current amongst its members a desire that one of the aims of this section of the Research and Clinical Committee should be to investigate this difficult and highly technical problem of standardization. Thus, after the preliminary work of the Sub-Committee on various schemes of research had been initiated, I was asked at the meeting on February 13, 1929, to prepare a memorandum on a standard method of performing the Wassermann test. This report was entirely of a preliminary nature, and intended only to form a basis of discussion. While this was in course of preparation a questionnaire was sent to those mental hospitals undertaking serological work, with a view to ascertaining and contrasting in some detail the methods employed by each. In order that all interests in the various branches of psychiatry should be fully represented, it was unanimously decided that all members of the General Paralysis, Mental Deficiency, and Encephalitis Sub-Committees should be invited to co-operate. Thus, on May 3, 1929, a conjoint meeting was held at Horton Mental Hospital, Epsom, under the chairmanship of Dr. J. R. Lord. In the memorandum I dealt mainly with the work of the three laboratory conferences held under the auspices of the League of Nations in November, 1922, November, 1923, and May, 1928, the latter, held at Copenhagen, being by far the most important in its results and influence upon the researches into the serology of syphilis.

The recent recrudescence of interest in the Boltz test, as evidenced by Dr. C. J. Thomas's paper on the subject, prompts us to publish further results obtained with this test, together with a few conclusions as to its value.

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

Ladies and Gentlemen,—I rise, as your President, with a feeling of what the older physicians called præcordial anxiety, chiefly because I am not a teacher of psychiatry, but merely a clinical physician, and therefore possibly may have no real mandate from the gods to address you, except that which I owe to the kindly hearts of my fellow members of our great Association. Whatever work I have done in Ireland in helping to keep alive our interests in psychiatry you have bounteously rewarded, and I heartily thank you, on my own behalf, and also on behalf of the Irish Division, for the great honour you have conferred upon me. The old Shakespearian tag says: “Some are born great, and some achieve greatness,” but I assuredly have had this “greatness thrust upon me.” It is difficult, all must admit, to leave “footprints in the sands of Time,” and, to one who succeeds such men as Conolly Norman, Dawson and Nolan—all Irish Presidents—the task is not easy. The older members will easily remember Sir Thomas Clouston, Dr. Urquhart, of Perth, Sir George Savage, and many others who have kept alive the knowledge of psychiatry and amply added to it, and we, who speak to you in, possibly, “childhood's treble tones,” and look at you through the oncoming “silvery fringes of the ‘arcus senilis,’” can only feel that the good work of clinical psychiatry will be carried on, in the curative interests of God's mentally afflicted, as it has been done in the past; and it will, I feel sure, be effectually perfected in the future by the younger members of to-day, graced with the present-day knowledge of biochemistry and the more modern methods of psycho-therapy.

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.

In a previous investigation (1) it was ascertained that the amount of cholesterol present in the serum of psychotic patients shows certain variations from the normal, and that it is influenced by the acuteness of the mental condition. Hypercholesterinæmia is usual in all forms of mental disorder except imbecility, and a fall in blood cholesterol content occurs during attacks of excitement, agitation or confusion. These results suggested an association between the blood cholesterol and the nervous system, probably by way of the sympathetic and endocrine gland systems.

This investigation was undertaken at the instance of the Mental Deficiency Sub-committee of the Research and Clinical Committee of the Association. It is an attempt to answer the question whether or not the order in which a mentally defective child is born into a family can have any influence as a cause of the mental defect.

The functions of the different layers of the neocortex are a matter of great importance to the neurologist.

The character of the neocortex and the significance of its different layers are, however, most easily understood when compared with the older forms of cortex, the primary olfactory cortex, which I have called palœocortex, and the secondary olfactory cortex or archicortex.

When the relations between self and environment are considered, a duality is found; the attention of the observer can either be consciously directed to objects, or objects can attract conscious attention. Thus, a gun fired unexpectedly in one's immediate neighbourhood would probably attract one's attention, whereas a row of runners lined up for the race are all “attention” in readiness for the sound of the gun. This duality I shall attempt to put in terms of my fundamental equation H + L = T.

Some explanation may seem to be necessary to account for further research into the question of sugar tolerance in psychotic subjects, as it may be thought that this line of research has been exhausted by the numerous workers in this field. A study of their work, however, shows that no critical attempt has been made to correlate the result of the sugar tolerance test with the mental and physical state of the subject at the actual time of the test. Instead, groups of patients suffering from certain psychoses have been investigated, and the results reported as percentages of abnormal curves in such psychoses. Thus, when it has been reported that a certain percentage of melancholics or schizophrenics show sustained hyperglycæmia after glucose ingestion, no attempt has been made to find out in what way these differed from the remainder in whom normal sugar tolerance was found.

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 acquiescing to Dr. Leeper's request that I should produce something for this Meeting, I thought that the best subject would be the relation of insanity to the parturient state. It is interesting to find that the description of the symptomatology of this disease only dates from 1875, when Fürstner (1) first described it.

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.

Since the introduction of the liver treatment for pernicious anæmia some four years ago that disease has received considerable publicity. It has been generally recognized as having three main clinical manifestations. Thus it may show itself as a blood disease, as a gastro-intestinal disease, or as a nervous lesion (subacute combined degeneration of the cord). It is, however, by no means generally recognized that pernicious anæmia has yet another way of manifesting itself, viz., by the occurrence of mental disorder. The object of this paper is to emphasize this fourth aspect of pernicious anæmia. In this country the subject has not hitherto received the consideration which is due to it. Nevertheless, a number of observers in other countries have shown, both by their own personal observations and from statistics, that mental disorders are frequently met with in the course of pernicious anæmia. The degree of mental affection varies in different cases. There may be merely a modification of character, with irritability and changing mood. W. Richardson would include in this mild group many patients described as uncooperative.