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.”

In the usual procedure of electronarcotic treatment, the electrodes are placed bitemporally and an initial electric current of 180 m.a. is applied for 30 seconds. During this period a tonic extension of the skeletal muscles occurs, accompanied by strong contraction of the pupils, which in the majority of cases are reduced to pin-point size. Slight convergence of the eyes may accompany the contraction. The contraction relaxes somewhat when clonus ensues, but usually becomes slightly more marked in the following stage when the electric current applied is between 60 and 80 m.a.

One can arrange the determinants of Rorschach responses in the following groups, according to the sense impression which they convey:

An optic sense impression only is given by the form-, colour- and vista-responses (F, C’, FC, CF, C, FK, K, k responses).

A kinaesthetic impression is conveyed in addition to the optic one by the movement responses (M, FM, m responses).

A tactile and optic impression is conveyed by the texture responses (c, CF, FC responses).

The swallowing of foreign bodies is more prevalent in prisons than in mental hospitals. Is it that there is something in the prison environment which causes some prisoners to swallow foreign bodies, or should the clue be sought for in the personalities of the swallowers? A few prison swallowers are insane, the great majority are not.

The subject of this contribution to the knowledge of reflexes is not the discovery of a new reflex or a new modification of an old one. On the contrary, the reflex at issue was described for the first time as far back as 1896 in the Lancet by W. Overend, who called it the “frontal reflex.” As has often happened with many other reflexes, it was overlooked and rediscovered many times after, and each of the authors gave to it another name. However, in spite of all these numerous contributions its practical clinical value remained of no importance, and it is scarcely mentioned in text-books dealing with nervous disorders.

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.

Mr. President, Ladies and Gentlemen: as my contribution to this morning's topic, “Legislation and Mental Health,” I had hoped to be able to give you the outlines of the proposals contained in a new Mental Health Bill under way in Northern Ireland. Time has not been on my side, as it just happens the Bill is being presented to-day for its first reading in the Northern Ireland Parliament, and as only after that will it be available for publication, I am not able to make use of it as the basis of my paper this morning.

I cannot tell whether it is purely a matter of chance that in Uppsala, a university town, I have had to treat difficulties at school in children of average or superior intelligence to a greater extent than in Stockholm where I practised earlier. It is obvious that everywhere the most usual cause of such difficulties is either subnormal intelligence or special difficulties in reading and writing, that can be classed among the aphasic disturbances, most commonly in the form of dyslexia. In Uppsala, however, I have encountered a relatively large number of cases with difficulties of other kinds that are not described, or only mentioned, in current textbooks on child psychiatry.

The generalized foetal dysplasia known as mongolism is one of the most frequent causes of severe mental defect. It accounts for something like 5 per cent. of all institutional cases in this country (Tredgold, 1929). The incidence of the condition in the general population is difficult to estimate with accuracy because of the high mortality it carries, but an exact knowledge of the frequency would be useful both for biological and for administrative reasons.

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.

Thiamine or aneurine has for many years been known as the anti-neuritic vitamin, although action of this substance in organic nervous trouble is not established. Less well-known is its action on the higher cerebral processes, but results of investigations appear to show that it has a definite effect on these. M. V. Dias (1947) found that the application of thiamine hydrochloride solution to the motor cortex of unanaesthetized dogs produced clonic contractions of the appropriate muscles, and Harrell (1946) reports striking psychological results on normal children.

Tashiro (1922) showed that the isolated frog nerve liberates ammonia on stimulation, and Richter and Dawson (1948) have recently found that ammonia is liberated on stimulation by the brain. Ammonia is very toxic to the brain, on which it has an irritant action; but the brain may be protected to some extent by the enzyme system described by Krebs (1935), which can detoxicate ammonia by combination with glutamic acid to form glutamine. Sapirstein (1943) obtained evidence that this system is active in vivo by showing that glutamic acid increases the resistance of animals to convulsions produced by injecting ammonium chloride. The toxic action of ammonia on the brain is also of interest in connection with the view that it may be concerned in certain forms of epilepsy (Harris, 1945). This view is supported by the observations of Price, Waelsch and Putnam (1943) on the inhibitory action of glutamic acid on petit mal attacks.

The treatment of depression with desoxyephedrine (pervitin or methedrine) is not new. In 1943 Davidoff reported a comparison of the effect of this preparation with amphetamine and dextroamphetamine on 8 normal and 8 depressed individuals. He found that desoxyephedrine gave the most rapid results, acted the longest and produced the greatest motor activity the most often.

Turpin and Bernyer (1947), working on the influence of heredity on the Arneth count (Cooke and Ponder's (1927) modification), found that in mongols it was shifted to the left, i.e., that their polymorphonuclears had fewer lobes and were therefore more immature.

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.

The adrenal cortex is the pivot of the body's reaction to stress. To this gland converge most of the varied effects of shock and stress, and from this gland diverge the steroids which, in ways but partly known, enable the body to withstand the stress. No apology is therefore needed for a study which contributes to an elucidation of the actions of these steroids.

Many writers on the subject of the treatment of addictions have suggested that for treatment to be efficacious, a period of detention legally enforced is necessary, and it is perhaps strange that a country which tends to regard personal failings and idiosyncrasies with a kindly eye has been probably the first to provide a method of enforcing it without recourse to a legal sentence.