You will, I am sure, share my regret that this lecture is being given out of turn. It had been arranged that my lecture should follow that of Prof. Mapother, whose untimely death robbed psychiatry of a notable figure and the Association of a lecture, possibly provocative and certainly stimulating, which promised to be a memorable addition to the series. I sadly miss, too, my old friend and colleague, Sir Hubert Bond, ever the kindliest and most charitable of critics.

In this paper it is my intention to give a broad survey of vitamin B complex deficiencies and their influence upon neuropsychiatric abnormalities generally, whilst Dr. Hardwick will discuss in greater detail the syndromes more specifically associated with such deficiencies, amplifying his remarks by reference to cases we have treated in recent years.

In 1943 I published a paper on pellagra, in which I described in summary form twelve clinical cases from amongst patients with a psychosis of long standing at West Park Hospital. I also referred briefly to two other cases seen at the observation unit at St. Pancras Hospital, one of whom died shortly after admission, the other being subsequently discharged recovered from West Park. Since then I have encountered from time to time further cases, both amongst the West Park patients and those of recent admission to the observation unit. The diagnosis in each instance was clinical, being based on the well-known symptomatology of symmetrical dermatitis, glossitis (and often stomatitis), malnutrition and, as a rule, diarrhoea. The frequent association of malnutrition with mental disease led one to suspect that milder vitamin-deficient states, i.e. intermediate between frank pellagra and healthy nutrition, existed. I think that our clinical observations, together with subsequent research along biochemical lines, go to support this. If one adds to the foregoing the major and minor B1 deficiency states, one is forced to the conclusion that one is not dealing with academic rarities, but with a practical problem of interest to psychiatrist, physician and dietician. Moreover, recent research has yielded us powerful therapeutic weapons, such as nicotinic acid, aneurin and riboflavine, which, with certain reservations, have a specific curative effect in the corresponding deficiency conditions.

The discovery of the nervous impulse established that the nervous system was fundamentally mechanistic, and that it was highly dynamic; and all subsequent work has confirmed these earlier views. The stabilities of inanimate dynamic systems are frequently of high importance and rich in applications. It would seem likely that an investigation of the stabilities of the nervous system would yield interesting results, but it is only recently that the importance of stability in the nervous system has been unequivocally recognized. But it has now been established that such properties are of central importance in the processes of integration and co-ordination. Advance has probably been hampered by the difficulties of the subject.

The congeries of etiological theories and alleged cures that has accumulated round the subject of nocturnal enuresis in children proves only one thing—that we know little of the causes and treatment of enuresis. Since the war many cases of nocturnal enuresis persisting into adolescence and adult life have been seen. Presumably the sufferers were ashamed of their disability and concealed it in peacetime. But wartime conscription, often entailing absence from their homes, has compelled them to reveal it. Such cases of persistent enuresis represent the most severe form of the disorder, and an analysis of the factors involved would seem to be of more value than merely to study enuretic children in general. Once these facts are ascertained, they may throw some light on the universal problem of enuresis in children.

The life of those sailors who are called to tasks of special peril under the sea is recognized as being strange, unnatural, full of hazard, and of necessity involving considerable strain. It is hardly remarkable, therefore, that the infrequency of mental breakdown among submariners has given rise to comment and conjecture by various authorities. Colonel Cutler (1944) of the U.S. Army, in a lecture entitled “A Surgeon Looks at Two Wars,” states that the lack of neurotic illness amongst submariners is due to the fact that there is no escape route. He points out that “there are statistical data to support the fact that where there is no escape route, these psychological casualties do not arise, or arise but rarely. Thus they are not reported for crews of submarines, and surely this might be thought of as a place for psychological strain …” This view is not accepted by all, and quite different explanations have been put forward. Surgeon-Captain Curran, R.N.V.R. (1944) believes that effective pre-selection and early elimination of the unsuitable are the two principal reasons for the small number of submariners who reach naval psychiatrists.

Numerous writers, doctors, psychologists and laymen interested in the cure of speech defects have discussed stuttering, a condition also known by various other names. Literature on this subject has been published by Kussmaul (1877), H. Gutzmann (1911), Froeschels (1925), Brown (1932), Hahn (1943), among others.

Kretschmer, in his Psychology of Men of Genius, drew attention to the frequent association of psychopathy in the mental make-up of individuals so gifted and so able as to be readily included in the class of “men of genius.” Of all the individuals whom Kretschmer discusses, Dostoievski is the only one who is known for certainty to have been epileptic. Both the prophet Mohamet and the apostle Paul are mentioned as being traditionally regarded as having suffered from this malady, but for obvious reasons it is impossible to be certain of this. That an individual who ranks amongst the world's greatest novelists should, throughout his life, have suffered from epilepsy is in itself a remarkable and possibly unique thing. It is therefore of some interest to inquire in what manner epilepsy manifested itself in Dostoievski, how it influenced his work, and what light, if any, the manifestation of this condition in an individual of such intellectual power, throws on the nature of the epileptic state itself.

The presenile psychoses have been the subject of intensive study in recent years. Both Alzheimer's and Pick's disease can now be regarded as well-defined clinico-pathological conditions. However, there occur cases with dementia developing in middle age or in early senium which do not fit into any of the established clinical types. A small group of cases characterized by dementia, extra-pyramidal symptoms and involvement of the spinal cord has been described by Jakob (1920) and Creutzfeldt (1920) independently. Similar cases have since been reported by Meyer (1929), Davison (1932), Jansen and Monrad-Krohn (1938), Davison and Rabiner (1940), and most recently by Jervis, Burdum and O'Neill (1942). McMenemy (1940), in a review of dementia in middle age, stated that the number of cases of that type reported in the literature did not exceed 14. Though all of them had the syndrome mentioned above in common, they varied considerably in respect of the leading symptoms. While in some the clinical picture was dominated by dementia associated with a variety of psychotic features, in others the extrapyramidal and in a few the spinal symptoms were predominant. Nothing definite is known about the etiology of that condition, though the hypothesis has been expressed that it may represent an atypical form of encephalitis. Josephy (1936) suggested that it might be a deficiency disease. No agreement has been reached on a suitable terminology. Jakob's original description of the condition as spastic pseudosclerosis has been found to be misleading. K. Wilson (1940) proposed to call it “cortico-striato-spinal degeneration.” Davison and Rabiner (1940) speak of “diffuse encephalomyelopathy.” Other authors advocated the provisional term Jakob-Creutzfeldt disease. In view of the scanty knowledge of the symptomatology and pathology of the disease, this term seems at present to be the most acceptable.

Psychiatrists constantly observe pathological attitudes towards mental and physical illness among their cases. At one end of the scale there are the hypochondriacal patients, with their increased awareness and over-emphasis of discomfort and deficiency; at the other end there are those who make light of, or even ignore, their disabilities. The psychiatrist is often faced with the task of modifying such abnormal attitudes. This aim can, in many cases, be achieved by psychotherapy, while in others physical treatment such as shock therapy or prefrontal leucotomy may prove successful. Both the abnormal attitudes towards illness and the success of treatment are as yet little understood. Possibly observations such as those on which we are going to report in this article may contribute to that problem. We refer to the symptoms of imperception and unawareness of gross physical disabilities in certain cases with lesions of the nervous system.

Until quite recently the mortality from cerebrospinal spinal fever was considerable, and those who survived the illness were considered lucky to be alive at all. As a result of chemotherapy, which has already reduced the case mortality to less than 9 per cent., more and more persons are likely to recover and present new problems. That some of these survivors may continue to complain of symptoms which incapacitatate them for work for prolonged periods has been borne out by some recent contributions (Pai, 1944; Degen et al., 1945; MacKieth, 1945; Ballard and Miller, 1945). In a previous paper (Pai, 1945) it was pointed out that some of these symptoms were psychogenic in origin, and others probably physiogenic, due to organic changes in the brain. Among the latter symptoms were changes in personality, intellectual deterioration, mild but persistent depression, occasional disorders of conduct and pronounced tendencies to invalidism. As personality consists to a great extent of several patterns of behaviour acquired in infancy and childhood, it was decided to study a group of patients who had cerebrospinal spinal fever in early life, in order to determine to what extent this illness had contributed to the development or the warping of the personality in each patient.

Convulsion therapy may now be considered to have established a position for itself in psychiatry, and in particular there is now a consensus of opinion that in states of depression occurring in later life it offers a chance of recovery for the patient unrivalled by any other form of therapy. The treatment is associated with a risk of causing compression fractures of the spinal vertebrae, and especially in the age-groups above 60 one is still concerned with the violence of the muscular spasm produced at the treatment. In July, 1939, at the Woodside Hospital we first commenced to study the problem of vertebral fractures complicating convulsion therapy, and also to investigate the general problems involved in rendering the treatment safe for our involutional cases. Our first attempt was with curarine, which we were enabled to give to a few of our patients in the psychiatric department of the Middlesex Hospital owing to the facilities placed at our disposal by the research pharmacological department.

The favourable results obtained in the treatment of early and late syphilis by penicillin fostered the hope that it would also be of benefit in cases of G.P.I. Accordingly, this method of treatment was instituted in a psychiatric hospital in M.E.F. (No. 78), and the results obtained in six cases are here recorded.

An interesting field for investigation and experiment is provided by the conditions formerly known as Little's disease or spastic diplegia, or hemiplegia, or spasticity with athetosis.

One hundred years ago Little studied cases of types now grouped under the common term “cerebral palsy.” His conclusions justified attempts at rehabilitation rather than surgical intervention.

In setting up the definitions of psychiatric conditions, the term “disorder” has been used for the designation of the generic group of the specific reactions, while the specific reaction types have been termed “reactions.” In classifying psychoneuroses, the dynamics of the psychopathology was chosen as the basis. Of necessity, a few terms remained descriptive (symptomatic). In general, an attempt has been made to retain only such formerly used terms as could be fitted into this general plan and omit categories which are “catch-alls,” such as “Simple adult maladjustment,” “Constitutional psychopathic state,” etc.