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primary abdominal pregnancy per se. Therefore Iam inclined to think that the pregnancy began in arudimentary horn, which lost its communicationwith the uterine cavity during the three years of thefoetus’s existence.

It is difficult to come to a definite conclusion as towhen the tubal pregnancy started-whether it wasa case of superfoetation or simultaneous ectopicpregnancies. Apparently, when the patient was

admitted the first time, she had gone to full term,and a spurious labour had occurred with severe

abdominal pain and vomiting. The foetus must havedied during that process.

Summary.The interest in this case lies in the following facts :

1. The woman lived fairly comfortably for nearlytwo and a half years with two dead foetuses in herabdomen. (a) One about eight months old lying ina special sac which was tightly adherent to theviscera, and apparently originating from the upperpole of the uterus from a rudimentary horn ; (b) theother in the right Fallopian tube over three monthsold, which had been there for an undeterminedtime.

2. The placenta of the large foetus was gangrenous,and the foetus itself was just beginning to undergodecomposition. ,

3. A rare combination of abdominal and tubal zitpregnancies. ’,

MENTAL DISEASE AND DEFICIENCY.WORK OF THE BOARD OF CONTROL

IN 1925.

THE twelfth annual report 1 of the Board of Control,on which we made some general comment last week,records that there were 133,883 certified persons undercare at the beginning of 1926. This was an increaseof over 2000 on the previous year, but theCommissioners consider that it is parallel with theincrease in population and does not afford evidenceof any increase in the incidence of insanity. Thesex percentage among the private patients was 34-8males and 65-2 females, but if service and ex-servicepatients are included the relative figures are alteredto 59 and 41. Among rate-aided patients the sexdistribution showed a slightly higher figure formales : 41-7 per cent., or 44-3 per cent. when theservice cases are included. The recovery-rate for thewhole country, calculated as usual on the directadmissions, was 31-8 per cent., and the death-rate7-6 per cent.-the lowest ever recorded.

Accommodation.The question of available accommodation is rapidly

becoming serious, and the Board called a conferencein April, 1925, to consider it. Methods of relievingpressure that were recommended include : (1) Arrange-ments with boards of guardians to transfer harmlesssenile patients to Poor-law institutions ; (2) extendeduse of boarding-out, discharge to relatives, anddischarge on trial of all suitable patients ; (3) buildingon to existing mental hospitals separate admissionand convalescent villas and homes for the nurses.As circumstances may differ in different areas, theBoard is collecting information with a view to callingregional conferences. Regions have been mapped outin such a way that each group of mental hospitalsis collected around a teaching centre, and it is hopedthat the scientific progress of psychiatry may befurthered by contact between the institutions and theuniversities.

Scientific Equipment.The report states that " every public mental

hospital should possess a laboratory " and urgesevery institution to appoint a properly trainedpathological officer and laboratory assistant without

1 H.M. Stationery Offioe. 12s. 6d.

delay. Possibly the grouping of the hospitals aroundthe universities may further the encouragement andcoordination of research by the appointment of oneof the university pathologists as visiting pathologistto the mental hospitals in his area. The Commissionersurge the speedy installation of an X ray apparatusand the appointment of a visiting radiologist ; it is

particularly important when dealing with mental

patients to be able to locate fractures and foreignbodies precisely, and also to be able to apply X raytreatment clinically where indicated. While itcannot yet be stated with any assurance that ultra-violet radiation has any specific action on psychoticstates, five county and one registered hospital haveinstalled the apparatus for the treatment of suchconditions as malnutrition, autotoxasmia, and tuber-culosis. The Commissioners feel that patients cannotbe adequately treated without a clinical room attachedto each ward where they can speak privately withthe medical officer and where he can carry out thesimple everyday tests of clinical medicine. A com-plaint of increasing frequency is the lack of opportunitythe patients have for talking with the medical officer,and although this is no doubt partly due to the verylarge numbers accommodated in some of the institu-tions, yet the Commissioners feel that the difficultymight be largely met by the routine use of theseclinical rooms.

Amenities of Life.In conformity with their general policy of treating

inmates of mental hospitals as nearly as possiblelike those of other hospitals, the Board urge thegreatest possible freedom in correspondence andvisits, and have issued a circular in which they askall superintendents to see that the patients are fullyinformed of their rights in the matter of visits, letters,and parcels.The scheme of dietary drawn up by the Board has

been followed in most of the hospitals, and there isno doubt that the food supplied has, on the whole,improved very markedly in recent years. Rigidweekly scales have been abolished, and kitchen equip-ment has been improved. The provision of a reallygood diet necessitates capital outlay on the equipment,but economy is effected in the end. The averageweekly cost of maintenance was 23s.

Infectious Disease.Three institutions had outbreaks of mild small-

pox, but there were no deaths, and the energeticaction of the medical staffs quickly confined theepidemics within narrow limits. Influenza seems tohave been more prevalent in 1925 than in 1924, butof a milder type. The problem of intestinal diseasein mental hospitals was dealt with in a recent issue ofTHE LANCET (August 21st, pp. 377-391). While themeasures taken to prevent and combat these condi-tions are very much more efficient than they used tobe, the report urges on all institutions the great impor-tance of making their water- and milk-supply, sewagedisposal, and laundry work above reproach. It is alsosuggested that the flushing system in w.c.’s should beworked by a floor pedal to avoid contact with handsthat may be contaminated. Typhoid and para-typhoid continue to show a slow but disquietingannual increase, 147 cases being notified during 1925.Curiously, neaily 80 per cent. of these cases are inwomen, whereas in the population outside malecases predominate. Early diagnosis and organisedsearch for carriers ought to combat these diseasessuccessfully. Dysentery has shown a steady decreasein incidence, while tuberculosis has remained at thelow figure it reached last year, less than 12 per 1000.The distribution of the last-named disease suggeststo the Commissioners that there are still some

unrecognised predisposing factors in certain hospitals.The figures of mortality from phthisis show a verygratifying improvement, from 17 per cent. of alldeaths in mental hospitals in 1909-14, to 11-4 per cent.in 1925. The improvement in dietary is probably the

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chief responsible factor, others being open-air nursing,better ventilation, and vacuum cleaning.

8taffs and Out-patient Treatment.Some half dozen superintendents resigned during

the year, and it is interesting to note that the firstappointment of a woman superintendent was madein the summer of 1925, when Dr. Jean Shortt wasplaced in charge of The Lawn, Lincoln. The problemof mental nurses was made the subject of a specialconference in April, 1925, and the Board subsequentlyissued a circular setting out their suggestions on whatshould be done to ensure a good services. The circularpresses for uniform action throughout the country toattract the best type of nurse by providing adequateremuneration, suitable quarters, and club rooms.

Those superintendents who have tried the experimentof using women nurses for male patients are practicallyunanimous in its favour.The report devotes a special section to the impor-

tance of providing out-patient treatment in connexionwith mental hospitals, and particularly emphasisesthe value of cooperation with general hospitals. Ascore of hospitals throughout the country now haveout-patient clinics, where patients are seen by a

member of the staff of a mental hospital ; but verymuch remains still to be done, and the necessity ofproviding beds and social workers for these clinicsis not yet adequately appreciated.

General Paralysis and Encephalitis Lethargica.Induced malaria was used at 42 institutions on

some 444 general paralytics in 1925. 13-7 per cent.of these have been sent home greatly improved andno harm has resulted from the treatment. The Boardadmits the point of view of those who maintain thatthe apparent recoveries should be classed with theremissions which so often occur without treatment,but feels that the figures are too striking to be depre-cated and continues to encourage this therapeuticexperiment. There are now in mental institutionsabout 320 patients suffering from the after-effects ofencephalitis lethargica. These young people needoccupational training and facilities for special group-ing, and the Board is glad to record that the localauthorities for London and Lancashire have collectedtheir cases together and that 30 beds have been

specially put aside at West Park, Epsom, for researchand treatment; 25 beds have also been set asideat Winchmore Hill, and the results of patient workthere have been gratifying.

Research Work in Mental Hospitals.The report includes, as usual, abstracts of the

research carried out in the various mental hospitals.The amount of research done, in addition to routinepathological work, is steadily increasing. This year’sreports record a number of interesting and valuablepieces of work on many subjects, including intestinalinfections, malarial treatment of general paralysis,basal metabolism, biochemistry of the blood, reactionof the cerebro-spinal fluid, pellagra, laboratory aidsto diagnosis, and ultra-violet light and radiant heatin treatment.

Mental Deficiency.A large section of the report is taken up with the

very serious problem of the mental defectives. Aswe pointed out in our comment on last year’s report(THE LANCET, 1925, ii., p. 655), the lack of accommoda-tion is acute, and the last 12 months have seen noimprovement. " The failure of local authorities," saysthe report, " to fulfil their duties is hampering thebeneficent objects of the Mental Deficiency Act.Every day brings to our notice urgent and oftenmost pitiable cases for whom no accommodation canbe found. Mere figures can never reveal the urgentneed for continuous care for defectives. There arehuman aspects of this social evil which cannot befound in statistics." Three typical cases are givenin full as illustration of the lamentable state of affairs.

Discussing the marriage and procreation of defec-tives, the report weighs the methods of sterilisation

and segregation, and in view of the terrible results,both social and personal, of the present free propaga-tion of deficients, suggests that the two measuresmight profitably be worked together. Sterilisationalone will certainly not solve the problem, nor affectthe immediate need for institutional accommodation,but since this is so grossly inadequate it might, theBoard feels, be both humane and expedient to trysterilisation followed by return to some form ofcommunity life on licence.While ascertainment is undoubtedly improving,

a large number of defectives have not yet been found.The reports of local authorities make it clear that aspecially trained officer should be appointed or elsethat the local voluntary association should be used.A circular has been sent to local authorities and 115out of 124 have replied ; the report gives a summaryof their answers. Twenty-one occupation centresare now at work and producing good results, in spiteof the lack of proper facilities in many places. Anincreasing number of boards of guardians are employ-ing skilled occupational trainers. The appointmentof special medical officers is proceeding slowly andthe Board doubts whether the Act will be properlyworked until each district has such an officer, withspecial knowledge and experience, whose principalwork is mental deficiency. There is considerabledifficulty in obtaining doctors with adequate training;only 108 out of the 333 so far appointed have hadany special experience. On Tan. 1st there were21,082 defectives under care and 55,480 " ascertained."The death-rate among those in institutions was 2 percent. ; 31 per cent. of these being due to tuberculosis,20 per cent. to pneumonia, and 11 per cent. to epilepsy.

MENTAL HOSPITAL REPORTS.

PRIVATE HOSPITALS.

Barnwood House Hospital, Gloucester, has 142patients, 14 of whom are on a voluntary basis. Therewas a good deal of influenza in the spring but no:)ther illness ; the death-rate was 9-15 per cent.The recovery-rate was 48 per cent., and the VisitingCommissioners note with satisfaction the amount oflndividual and intensive treatment. The staff ofvisiting specialists is increasing ; the hospital nowhas a consultant physician, surgeon, and pathologist,and a dentist is to be appointed. One generalparalytic treated by induced malaria was dischargedrecovered and is keeping well. The patients had theadvantage of a seaside house at Weston-super-Marefor the summer and many of them have full parole.Verandahs and a dental room were added during theyear and new arrangements at the cowsheds haveresulted in a milk-supply of high purity. Forty-oneper cent. of the nursing staff hold their M.P.A.certificate.

The Retreat at York publishes a report illustratedwith delightful pencil drawings of the estate. Therewere 206 patients in residence at the beginning of1926. The number of admissions during 1925 reacheda record figure and over 56 per cent. of them werevoluntary. The death-rate was 7 per cent., and therecovery-rate 28 per cent. The hospital was freefrom epidemic disease. Malarial treatment of generalparalysis has been continued with varying but onthe whole encouraging results, and the use of glandextracts is being pursued. Many of the patients hadthe benefit of a "summer holiday" in the houserented at Cloughton. The male side has beensatisfactorily reorganised and the Gentlemen’sAdmission Hospital is described as "a model ofwhat such a department should be." A new nurses’home is practically complete. Fifteen patients havefull parole and 48 more walk out attended. Twelvenurses obtained the M.P.A. certificate during theyear and a number more passed the preliminaryexamination. A most important development is theinauguration of a clinic at the County Hospital formental out-patients, which is to be run with thecooperation of the five mental hospitals in the district.