The origin of the term abreaction dates from the time of Breuer and Freud's (1) early studies in hysteria, when they observed that patients were helped by “just talking it out.” Later their technique was employed under hypnosis (2). Sadler (3) defined abreaction as “a process of reviving the memory of a repressed unpleasant experience and expressing in speech and action the emotions related to it, thereby relieving the personality of its influence.” Miller (4) quotes Freud as holding that experiences shall be recalled with emotional vividness. “Affectless memories are almost useless,” said Freud.

Does convulsive therapy in the depressive states produce its effect by some action on the pituitary and hypothalamus? This is a question which we at Barnwood House and at the Burden Neurological Institute are trying to answer.

This year marks the seven hundredth anniversary of the foundling of the House of Bethlem. Seven hundred years! It takes us back to the very beginnings of English culture. Much in our constitution that we hold dear dates from this thirteenth century, which saw the foundation of Bethlem. In 1215 King John signed the Magna Carta, and in 1265 Simon de Montfort summoned not only the knights of the shire, but for the first time two representatives from each of the chartered boroughs, the precursor of the House of Commons. It was between these two dates on the Wednesday after the Feast of St. Luke the Evangelist, which in the year 1247 fell on 23 October, that Simon FitzMary, a citizen of London, signed the deed-poll which founded this hospital. He had given and granted to God and the church of St. Mary of Bethlem all that land of his which he had in the parish of St. Botolph without Bishopsgate London, to wit, all that he had or might have there, in houses, gardens, orchards, fish-ponds, ditches, marshes and all other things appertaining thereto as defined by their boundaries. These extended in length from the king's highway on the east to that ditch on the west which was called Depeditch, and in breadth to the land which belonged to Ralph Dunning on the north and to the land of St. Botolph's church on the south. The gift was for the formation of a priory under the rule and order of the church of Bethlem, the brothers and sisters to wear publicly upon their copes and mantles the badge of a star. He further declared in the deed poll that: “For the greater security of this gift I have placed myself and mine outside the said property, and I have solemnly put in actual possession of it, and have handed over the possession of all things aforesaid to the lord Godfrey of the family of the Prefetti of the city of Rome, at this time bishop-elect of Bethlem (as by our lord the pope confirmed) and at this time actually in England, in his own name, and in that of his successors, and in the name of the chapter of the church of Bethlem. And he has received possession of the said property, and has entered upon it in the form prescribed.”

Von Winiwarter, in 1879, published his pathological findings in a case in which there was obliteration of the vessels of the leg due, as he considered, to a proliferative process in the intima, that is to say, an “endarteritis obliterans.” Other views on the pathology came to be propounded, notably that of van Manteuffel, who considered that consequent upon arteriosclerosis of the popliteal artery a white thrombus formed, which, spreading peripherally and becoming organized, produced the picture of an obliterative endarteritis. Twenty-five years after Winiwarter's paper Buerger published his observations based on 30 cases, with pathological studies on the vessels obtained from eleven amputated limbs. He disagreed with the views of both von Winiwarter and von Manteuffel. He found that besides an extensive obliteration of the larger arteries and veins there was a varying degree of peri-arteritis and arteriosclerotic thickening of the vessel wall, and concluded that the condition was a thrombotic process occurring in the arteries and veins, followed by organization and canalization, and not an obliterating endarteritis. He absolved the intima from any “considerable role in the genesis of the thrombotic process,” and attributed the thickening of the intima and the cellular infiltration and vascularization of the media and adventitia to the agency producing the coagulation of the blood and to the changes in the thrombus itself. He saw the final lesion as a vessel obliterated by dense connective tissue, canalized, together with some residual cellular infiltration and capillarization of the media and greater or less thickening of the adventitia and periarterial tissues, the thrombus having disappeared in the course of the development of this final result. He proposed the term “thrombo-angeitis obliterans” for the condition, and with the general adoption of the term Buerger's name came to be linked with it.

From time to time in the Middle East, cases were admitted into hospital bearing the diagnosis of Mepacrine Psychosis. This was a label which one hesitated to accept because, for one thing, the cases presented no single clinical type, and for another, they showed, with few exceptions, little or no evidence of symptoms of an organic reaction type such as might be expected in a toxic psychosis. It was, moreover, important, in view of the widespread use of mepacrine both as prophylactic against malaria and in the treatment of it, that the occurrence of a psychosis during the exhibition of mepacrine should not be ascribed to it, except on the irrefutable evidence of a causal connection between the two. Though I have no figures to indicate the incidence of mepacrine psychosis relative to the number of cases of malaria treated with the drug in the M.E.F., I believe the ratio to be very small indeed. Kingsbury mentions 12 cases among several thousand cases of malaria treated with mepacrine; Allen et al. quote Greene as having encountered 2 cases in a series of 750 so treated, in Malay. Hoops had 1 case of mental excitement among 1,207 cases; Briercliffe 15 cases of delirium among some hundred persons taking mepacrine. Field estimated the incidence of mepacrine psychosis to be less than 01 per cent. of cases treated. Gaskill and Fitz-Hugh noted 35 cases of toxic psychosis in 7,064 cases of malaria treated with mepacrine in an army hospital during the recent war; Mergener reports 1 case in 1,000, and quotes Udalagama, who recorded 7 such cases in a series of 644, and Bispham, who noted only 1 case in 7,915 cases that came under his personal supervision, and who up to 1941 found only 35 instances in the literature. Burnham quotes Dove as having noted no case of alarming reactions (presumably including psychotic reaction) in a series of 30,000 cases treated with mepacrine.

This child developed signs of a serious mental illness during an attack of jaundice three years ago, just before his 11th birthday, and the condition has continued to develop up to the present time, though not quite evenly. At one period the illness was thought to have remitted, but it is evident in retrospect that the remission was, in fact, characterized by regression in behaviour and considerable invalidism. The clinical picture showed sustained mutism and one postural oddity as the most prominent features; and in other respects the child showed an interest in his environment and participation in outside activities which in an adult with a similar diagnosis would be regarded as unusual. There was a morbid heredity in the case and a personality of distinctly pathological character which was clearly shown by his behaviour during his early years. The genesis of the reaction was complicated by an acute infective illness and by two head injuries, neither of which now appears to have been of importance, but which led to much clinical obscurity at the time. The anomalous clinical pattern and the inability of the child to communicate his experiences illustrate the difficulties of diagnosis at this age, and an attempt is made here to outline other possibilities which need consideration and the reasons in this case for rejecting them.

Modern treatment of epilepsy is directed towards (1) the control of the fits, and (2) the diminution or abolition of the underlying cerebral dysrhythmia.

In this paper I shall give my personal observations on 196 patients treated with epanutin in the Maghull Colony over a period of 6 years.