Those responsible for these lectures took their courage in both hands when they chose me to follow in the line of the eminent doctors and lawyers who preceded me. For I am in no way a Very Important Person. I held the lowest of judicial offices, though in my opinion one of the most important. But while emphasizing your courage, I want to assure you very sincerely that I am fully conscious that it is a great honour to be selected for this task. Indeed, I am somewhat overawed, but I can only try my best.

Electroshock therapy, first introduced to this country by Fleming, Golla and Grey Walter in 1939, has long passed its period of probation and is now universally accepted as active and effective. Yet its mode of action is still unknown. The variety of theories propounded to explain its action establishes only the degree of our uncertainty. To advance our knowledge of its mode of action has been the aim of the work described in this paper.

It is perhaps of some small interest that the President of the Section of Neurology delivered last week in this building an address on “The Borders of Neurology,” and that for to-night I had chosen to speak on what is obviously a related topic, the “Tasks of Psychiatry.” It is, of course, possible that behind this choice of our titles there may simply be a geriatric problem, for the President of the Section of Neurology and I worked together as members of the same Field Ambulance in the Battle of the Somme, just over 32 years ago. On the other hand, there may be more than this in it, and perhaps we really do need to define our fields rather more clearly and to make sure what our tasks are, and how we are best to meet them. In fact, I think that the question of the actual borders of psychiatry, as apart from its tasks, was dealt with quite convincingly in the Joint Report of the Royal College of Physicians, the B. M. A. Psychological Medicine Group and the Royal Medico-Psychological Association.

In 1939 an inquiry was begun into the late results of the type of head injury which results from collisions on the roads, from accidents in industry and from falls in the home. Since penetrating injuries resulting from civilian accidents are extremely rare, the examples that were encountered have been eliminated from the final reckonings and so the following account is concerned entirely with the so-called closed type of injury. It must, of course, be realized that compounding and infection are common even in this type of injury, because cranial fractures frequently run across and open into the paranasal air sinuses.

We need no longer dally over theories of the mind-body relationship; we need not even speak of the integration of body and mind, for that integration is not just the combining of parts to form a whole; the unity of any organism has existed from its first beginnings, evolutionary or individual. Myers (13) and Russell (18), by introducing a concept of “the directiveness of organic activities,” have defined this essential and intrinsic unity even more cogently than the many other exponents of the same theme. The unicellular amoeba, at one end of the evolutionary ladder, has all the biological capacities of man at the other end. The fertilized ovum develops from within itself all the specialized parts and functions of the higher animals. The unity, then, has been there from the beginning. The complexity of man is not an integration, but is a delegation of functions. As Russell says, the directiveness and creativeness of mind are but a specialized development of the directiveness and creativeness inherent in all living matter.

Allen's work (1, 2, 3, 4) in this series has dealt with the test performance of the brain injured and brain diseased patients. Results of the two groups on the Bellevue Intelligence Scale, Form 1, have been adequately reported both separately and comparatively. The purpose of this paper is to combine the two groups in order to analyze the test results as one group, i. e. encephalopathic group. The study of these test results includes an item analysis of subtest results obtained by this group, and a comparison of verbal with performance scores to ascertain a valid basis for scatter analysis.

Clinicians often assume, in a somewhat casual manner, that injury to the brain at birth has been the cause of this or that case of defect. Cerebral diplegia, hemiplegia, hydrocephaly and numerous types of cerebral maldevelopment have been attributed to this cause. Some American psychologists have tended to ascribe to birth injury every case of defect with plegia (Doll, Phelps and Melcher, 1932). Equally categorical denials of the influence of birth trauma in the aetiology of mental defects have been expressed (Berry, 1933). The decision between these opposing points of view involves the examination of some difficult questions. There are two rather obvious principles to be applied. First, any case in which birth injury is diagnosed must present symptoms or signs, which could reasonably be attributed to this cause. Secondly, a history of events at the time of birth must be ascertained and the evidence carefully weighed with a view to finding out whether conditions likely to produce injury were present. A third point to be kept in mind is that, even when proof of cerebral injury at birth is reasonably complete, the effect of such injury on the intelligence level has still to be assessed. In any given case of defect with a possibility of birth injury, we must ask ourselves what the intellectual level would have been in the absence of such injury.

Electronarcosis is considered in some places to be as good as insulin in the treatment of schizophrenia (1, 2, 3, 4). One publication on the subject emphatically states that electronarcosis is only equivalent to E.C.T. as a therapeutic measure (5). There is such a marked difference of opinion in these preliminary reports that one wonders if we are dealing with the same procedure.

To estimate the radical change that has come over medicine since the turn of the century it is worth considering for a moment the recently republished classical writings of J. Hughlings Jackson on Epilepsy and Epileptiform Convulsions. (1) Extensive and detailed as they are, they contain no hint of a possible psychological approach either to etiology or therapy. Both indeed are specifically rejected, the author taking the greatest pains throughout to keep psychology at a distance, as if it had no place in medicine proper. For instance, he describes most minutely the many and varied mental symptoms associated with epileptic attacks—both those before and those after the attack, when his acute clinical sense often takes him a long way; in his description and discussion of the “intellectual aura” and the “dreamy states” he would seem to be close to some modern views and discoveries. But for him such symptoms are only aids to diagnosis, mere pointers to underlying structural damage of the central nervous system, which is his only concern—viz. “Admitting that all mental states have parallel physical states I think our direct concern as … physicians is with the latter only” (vol. 1, p. 169). He comes to the conclusion that the study of epilepsy with a “psychological habit of mind” is “unfruitful.”

The present paper is based upon the investigation of 95 brains of patients dying some time after leucotomy, and mainly, though not exclusively, upon the 45 cases in which the survival period was more than 5 months (up to 5 years). In a third of the total material and in about half of the 45 cases with survival longer than 5 months a full microscopical investigation has been carried out or is nearing completion. Eventually all the informative cases will have been so examined, but investigation by serial sections of considerable parts of the brain is a time-consuming undertaking. An unfortunately irremediable defect in our material is the unevenness and incompleteness of the clinical, physiological and psychological investigations of the patients. Obviously only limited correlation studies can be carried out on such material. Again, the number of fully recovered cases in our material is small, in fact only some four (Nos. 66, 71, 10 and 18) of the total could be classed as such. The reason for this is that fully recovered patients are likely to die from intercurrent disease outside mental hospitals, when it is difficult to procure a post-mortem.

Treatment by prefrontal leucotomy, though undoubtedly of value, still rests upon an insufficiently scientific basis. Its anatomical and physiological effects are being increasingly discovered, but many of its psychological effects are still unpredictable and obscure. Its effect on intelligence, on immediate memory, and on simple learning ability are now well known, but with these we are not concerned. Rather, we have attempted to assess the effect of leucotomy on “creative ability.” By this phrase we shall refer to that ability by which the ideational content of past experience is utilized in a situation to provide concepts and actions not directly evoked by the new situation, but elaborated by the patient's more complex cerebral reactions to the situation; The ability is worthy of examination, since the more intellectual the work the more is it evident. The architect, for instance, needs more creative ability than the bricklayer, the novelist more than the amanuensis, and the Royal Academician more than the house painter.

The 68 patients surveyed in this paper form a companion group to the equal number who have been discharged from hospital and of whom a follow-up study has been published by Frankl and Mayer-Gross (1947). The patients' condition was studied during the early months of 1947, when they had remained in hospital from 1 to 4 years after operation or had returned after an unsuccessful attempt at discharge. To what extent they have to be considered as failures will be seen in the paper. They are of special interest not only as a contrast to the more successfully treated patients, but also because a closer observation of the course of their illness was possible than with the discharged group. Being under constant clinical observation since the operation, all significant changes in their condition have been recorded and the important problem of relapse, neglected in the large literature on leucotomy, can be discussed on the basis of these observations. Finally, an answer was sought to the question of why these patients should have reacted less favourably to the operation than their fellows.

Considerable material is available about the effect of leucotomy on intelligence. There are, however, few reports of objective measures of changes after leucotomy in the non-intellectual aspect of personality, those changes of temperament and character which are so striking to the clinician. In order to make a small contribution to filling this gap, at the suggestion of Dr. Desmond Curran an investigation has been carried out at St. George's Hospital and its In-Patient Unit at the Atkinson Morley Hospital, London.

Mr. Cecil Gray, in his excellent study, Peter Warlock holds the view that Philip Heseltine's character only becomes understandable if he is regarded as an example of dual personality. Gray gives very clearly and, in my opinion, conclusively the evidence on which he bases this belief. The only question that is left unanswered is the clinical nature of the duality.

Communicated mental illness or “folie à deux” in which the parent appears to have influenced the child is a frequently found disturbance in general practice and Child Guidance Clinics. The child is especially disposed to such a disturbance because he lives during the first years of his life in almost complete identification with the parents' psyche. In a healthy environment his growing consciousness will gradually resolve this identity, and thereby develop his ego and individuality. If, however, one or both parents suffer from mental illness this process is liable to be disturbed, and the child will remain fixated to the disordered psyche of the parent.