Although much work has been done on the physiological concomitants of affective states, nothing is known of any objective bodily changes accompanying thought processes, and yet the most superficial observation of lip, facial and eye movements, of unconscious gesture and restlessness furnishes indications of some of the more obvious somatic accompaniments of non-emotional mental activity.

When von Meduna in 1935 introduced convulsion therapy, his hypothesis that schizophrenia and epilepsy were incompatible diseases suggested that convulsion therapy was applicable only to cases of schizophrenia. Similarly, Sakel, when introducing insulin shock, proposed it as a treatment to be applied essentially to schizophrenia. It is thus not surprising that most psychiatrists at first devoted their main attention to comparing the results obtained from treating schizophrenia by these alternative methods of “shock” rather than in studying their effects on other forms of psychosis. However, Low and co-workers (1) in 1938 reported having obtained very encouraging results from giving metrazol-induced convulsions to a group of sixteen manic-depressive cases, and very shortly afterwards Bennett (2) issued a preliminary report on ten cases of the depressive psychosis in which he stated he had found a remarkable improvement following cardiazol convulsion treatment.

The range of psycho-pathological conditions for which the term “fugue” has been used has increased considerably and is still increasing. Originally the term was chosen to denote transitory abnormal behaviour characterized by aimless wandering and more or less marked alteration of consciousness, usually but not necessarily followed by amnesia. At present it is used for a variety of different symptoms, some of which have little in common; the psychiatrist using the term has to define what kind of fugue he means if he wishes to avoid misunderstanding and confusion. The reasons for the great popularity of the term are manifold. It is short, handy, vague, and has even a distinguished foreign flavour. But there are other reasons apart from those virtues. When the psychological mechanisms underlying abnormal behaviour were first studied two were regarded as responsible for the origin of fugues: dissociation and escape. From that time dates the tendency to describe as fugue nearly every condition of transitory alteration of consciousness which can be understood as the result of those mechanisms. Thus a remarkable change of conception has taken place; while the term “fugue” originally described a certain type of abnormal behaviour characterized by running away and wandering under a strong impulse and associated with clouding or narrowing of consciousness, it later came to be used, in addition, as the description of various results of the psychological mechanism of escape, without regard for the resulting behaviour. Obviously the fact that fugue means escape invited that change of conception. Considering the grèat number of neurotic and psychotic symptoms in the origin of which the two mechanisms mentioned above are supposed to play a part, there are hardly any limits to the use of the term. It is not intended to survey the whole literature on what has been called fugues; a few instances from current text-books and recent articles will demonstrate for how many conditions the term has been used in recent years.

In 1938 Wespi (1) in Germany and Stalker (2) in this country reported cases of crush fracture of the spine following cardiazol convulsion therapy. It was not until then, some four years after its introduction, that attention was focused on the risk of fracture in this form of therapy. During 1939 alarming reports appeared, especially in the United States, regarding the occurrence of such mechanical injury. Polatin et al. (3) radiographed 51 cases following metrazol convulsive therapy and reported spinal fractures in 43 per cent. Bennett and Fitzpatrick (4) in a similarly treated series of cases recorded 47 per cent. spinal fractures. However, the latter figure was obtained from a series of only 18 cases, and should therefore be accepted with reserve. In this country H. A. Palmer (5) in a series of 20 cases treated by cardiazol shock therapy found spinal fractures in no less than 5 cases (25 per cent.).

Damage to the frontal lobe is liable to produce personality changes; it is highly probable that lesions have to be bilateral to have this effect. But beyond that, there is little agreement about type, extent and localization within the frontal lobe of the lesions which are followed by personality change. Little is known about the different types of clinical picture caused by bilateral frontal lesions. In a certain proportion of the cases euphoria is the most impressive symptom, and it is for this reason that operations on the frontal lobes have been proposed in the treatment of depressions. (Lit., see Hutton.) The value of the procedure is still under discussion, and its theoretical foundation is far from being understood. This is not surprising, for if one tries to analyse such an operation, one has to take into account at least four variables: the patient's previous personality, his mental illness, the psycho-physiological effect of the lesion, and the psychological effect of operation, nursing care and environmental changes. The cerebral factor is obviously the most interesting one; to judge its importance one tends to interpret the operative results in the light of experience after other frontal operations or injuries.

Re-examination of the various problems arising from psychoses following childbirth is of interest for various reasons. Firstly, their place in the system of psychiatry is far from clear; their original description under the term “puerperal insanity” (Kraepelin) had given rise to the idea that they represented a clinical entity. According to Kraepelin the great majority of these psychoses take the form of catatonic states and only a few are of the manic-depressive group. More recent investigators, however, have shown that there is no psychotic reaction peculiar to childbirth (Clarke, Kilpatrick and Tiebout, Zilboorg, Saunders, James, Strecker and Ebaugh, Harris, Karnosh and Hope, and Piker). In these contributions the importance of the accompanying environmental and sociological factors has also received consideration.

In the early days of convulsion therapy many chronic psychotics were treated by this method in the hope of effecting a cure. While temporary improvement was achieved in most cases, results were disappointing, owing to the rapidity with which relapses occurred. With cardiazol as the convulsant, various complications, such as sclerosis of veins, tachycardia, vomiting and, most of all, aversion to the treatment on the part of the patient made its continued repetition impracticable.

It has long been recognized that standardized tests of intelligence, when used with psychotic subjects, cease to be valid measures of native intellectual endowment. This does not mean, however, that it is useless to employ such tests in the study of the mentally ill. On the contrary, the intelligence test still provides us with the best objective measure of the present intellectual efficiency of the patient.

The case about to be described showed during the 18 months when she was under close observation certain remarkable pathological endocrine features. These, viewed together and in retrospect, throw considerable light on the relationship between pituitary function and so-called anorexia nervosa, and introduce a broader conception of the latter somewhat misleading designation.

In the development of involutional melancholia a variety of causes have from time to time been implicated, ranging from glandular upset of ovarian or pituitary origin to the stress of air-raids. In the bulk of cases the pathogenesis would appear to depend on the interaction of a constellation of predisposing and precipitating factors. In the present study a tentative attempt has been made to indicate a possible ethnic element in the aetiology of this psychosis.

In the treatment of involutional melancholia the administration of oestrogenic substances has for years been a feature. The results achieved with this form of therapy have varied, some workers claiming unqualified success, and others recording no change, or even deterioration in their patients.

As a rule, in hospital practice there’ is little urgency for a rapid diagnosis in idiopathic epilepsy to be effected, and doubtful cases can be submitted to prolonged observation until an actual seizure has resulted. There are, however, certain occasions when the necessity arises for the establishment of a definite diagnosis as early as possible. In the average hospital case, the period of observation necessary will be a matter of days or, at the most, a week or so, but in cases of irregular seizures at infrequent intervals, this period may have to be extended into months before any opinion can be offered. It is with a view to curtailing this period of observation that an attempt has been made in this investigation to determine a method whereby the condition can be diagnosed with a degree of certainty in the absence of seizures.