I am satisfied one of the results, if not the objective, of medical education is for doctors to judge their success, or the state of progress of any branch of medicine, against a pathological rather than a sociological criterion. This is the inevitable effect of the amount of time and attention given to pathology in the medical curriculum, and is further reinforced by what is asked in examinations.

Traditionally, the problem for the doctor is to try to determine the pathological lesion, using this term at best in a wide sense, and to control this if he can; and the pathological criterion of disease he has in mind is an objective physical criterion, demonstrable in life or after death.

As we all know, no pathological lesion in this traditional sense is demonstrable in a large number of patients who go, or are brought, to see doctors. All physical examinations and investigations prove negative. Medicine is therefore faced with the dilemma in these cases of either (a) coming to the conclusion that there is nothing wrong, which is often clearly untenable, or (b) of expanding its scope almost indefinitely to cover every type of maladjustment.

It is perhaps not surprising that there have been no studies on the leucotomized patients' attitudes to the operation and its effects. There has been no practical reason for giving that problem special attention. Leucotomized patients have not spontaneously voiced complaints about the operation, even when the result was unsatisfactory. It seems that their apparent silence has been taken so much for granted that psychiatrists have failed to realize that it is an astonishing phenomenon. Here is a group of patients who have been subjected to an operation of which the pros and cons have been widely discussed in public. Many have left hospital free from symptoms but socially handicapped by the side-effects of the operation. Yet there has been, as far as this writer is aware, no instance of litigation in connection with the surgical treatment of mental illness. Part of the explanation for what seems to be a collective indifference to, if not general approval of, the operation and its effects may be found in the type of mental disorder for which this treatment has been most frequently applied: among the patients thus treated there have been many schizophrenics who even after the operation remained out of touch with reality, but that explanation does not apply to the numerous patients who were operated on for affective illnesses and neuroses.

In recent years efforts have been made to analyse the part played by the frontal lobes in the integration of personality. The pioneer work of Bianchi (1922) based on pathological lesions in human subjects, and on experimental bilateral ablations in monkeys, dogs and foxes, still appears to be as true to-day as when originally enunciated. Sherrington (1901) also described the changes following destruction of the frontal lobes. It was noted that such animals lost the power to learn and to enjoy themselves. They had no curiosity, but became restless, hyperactive and easily distracted. Brickner (1936) studied over many years a patient with bilateral frontal lobectomy who showed a diminished ability to synthesize abstract thoughts. Goldstein (1941) found that patients with frontal lobe damage lose their power for abstract thought and this is replaced by concrete behaviour, as shown by object grouping tests and their use of words. Similarly Penfield and Hebb (1940), in a case of extensive lobectomy for an infiltrating oligodendroglioma in an intelligent housewife, described a lack of ability for complex planning, such as is necessary for preparing a meal of several courses. Jefferson (1937) was unable to find any deficiency in cases of unilateral lobectomy. Rylander (1939), on the contrary, after lobectomy for tumours was able to detect changes similar to those found by Goldstein, and in cases with frontal lobe injury he found a lack of social sense. These patients were embarrassingly outspoken, and sometimes showed excessive activity or fatigue. Hebb (1945) concluded that studies on pathological lesions of the frontal lobes were not very helpful, owing to the lack of precision of the lesions due to the uncertain extent of the pathology.

Recent research has given rise to the hope that the secretory products of the adrenal cortex might be useful in the treatment of schizophrenia.

Two main lines of research have stimulated renewed interest in the role of the adrenal cortex in the pathophysiology of schizophrenia. A number of investigations have produced evidence that the responsivity of the adrenal cortex of schizophrenic patients to stress is lower than that of normal controls (Freeman et al., 1944; Hoagland et al., 1946; Pincus and Elmadjian, 1946; Pincus et al., 1949).

Another series of investigations has shown that adrenocortical activity is stimulated by insulin coma therapy, electronarcosis and electroconvulsive therapy (Hemphill and Reiss, 1942; Mikkelsen and Hutchins, 1948; Rees (1949a); Parson et al., 1949).

Cranswick and Hall (1950) reported that desoxycortone acetate and ascorbic acid appeared to be therapeutically valuable in schizophrenia. Rees and King (1951) carried out a controlled investigation on the treatment of schizophrenia with desoxycortone acetate and ascorbic acid, and found no evidence that the method was of any therapeutic value. It was pointed out that the investigation did not preclude the possibility that other products of the adrenal cortex might be therapeutically useful in schizophrenia.

The present paper describes a controlled investigation in the therapeutic value of cortisone administration in schizophrenia.

We are indebted to Dr. Ernest Evans, Consultant Physician, East Glamorgan Hospital, for making available a supply of cortisone for the investigation.

This report of about 150 children is based on recent experience gained in the Maudsley Hospital Children's Department, in which epileptic children are investigated at special sessions. Most of the patients were examined in the usual way on their first visit to the Department. A full psychiatric history was taken from the mother or other relation. Intelligence tests, electroencephalogram (E.E.G.) and physical examinations were carried out. Later, as indicated, further special tests, such as air encephalograms, were done.

It is important to note the type of patients discussed in this report, in view of the notorious difficulty of obtaining reliable statistics in such a subject as epilepsy, whose manifestations are so varied that any one hospital or clinic cannot expect to see a truly unbiased sample. Children referred to the Maudsley Hospital nearly always show some behaviour disorder, but lack gross neurological signs and symptoms. Even in the case of epileptics a behaviour problem is frequently the presenting complaint, the actual seizures being a secondary problem. As the facilities for investigation are better than in many other clinics, cases are frequently referred from other hospitals for special investigation. This material, therefore, is undoubtedly heavily weighted by epileptics with behaviour problems. There are, on the one hand, disproportionately too few mentally normal children with epilepsy, and on the other, too few with epilepsy in association with grosser neurological disorders. No attempt is made, therefore, to give any statistics on the incidence of a particular symptom or sign within this group, as it is meaningless in relation to the whole body of epilepsy in children. The recent outstanding book by Bridge (1950) gives a very fair picture of epilepsy in childhood.

The aetiological factors may be divided into two groups: those within the social situation and those within the child.

This investigation deals with the measurement, by a peripheral method of discontinuous spectroscopic oximetry, of the arterial blood oxygen saturation levels in a group of schizophrenic patients undergoing insulin coma therapy.

The association between tissue anoxia and insulin hypoglycaemia was first established by Campbell and Dudley in 1924. Dameshek and Meyerson (1935), using the arterio-venous oxygen difference method with the internal jugular vein as the source of venous blood, showed that the injection of insulin in coma doses was accompanied by an anoxaemia in the schizophrenic patients they studied. This work was confirmed by Himwich, Bowman et al. (1939), and in another paper Himwich (1951, p. 277) and his co-workers found that the correlation of progressively developing clinical symptoms with the decrease of cerebral oxygen uptake was a closer one than the correlation with the more acute fall in the blood-sugar curve. An important symptomatic aspect of insulin hypoglycaemia includes the progressive changes in the levels of consciousness accompanying the approach towards coma. Wilder (1943) has outlined some of these changes, and Frostig (1940) and Himwich (1951, pp. 258-265) have delineated these awareness thresholds and discussed their relationship to the Hughlings Jackson theory of the phyletic organization of the central nervous system. Thus, during the first hour following insulin injection, somnolence and lassitude appear to be associated with suppression of cortical and cerebellar activity; in the second hour further clouding of consciousness, sometimes with excitement, perceptual disturbances, periods of confusion, exacerbations of previously existing hallucinations and latent psychotic syndromes are seen; in the third hour motor restlessness and loss of consciousness suggest the release of basal ganglia and hypothalamus; in the fourth hour deepening stupor and depression of exteroceptive sensitivity indicate a probable release of the midbrain and suppression of pyramidal function; in the fifth hour the deep pre-mortal coma presages medullary release. Similarly, it is with awareness changes that many workers prefer to diagnose the “real coma” level in a patient under treatment. Thus Sakel (1937) held that coma was to be diagnosed when no further personal contact with the patient was possible, and Kalinowsky and Hoch (1946) agree that the real coma level is reached when it is completely impossible to awaken the patient.

The fact that electrical stimulation of the brain can produce unconsciousness in man and animals has been known since the eighteenth century, and from time to time this knowledge has been used in the production of anaesthesia for surgical purposes; Hobday, in 1932, performed castrations and herniotomies in small animals under electrical general anaesthesia, and in 1935 Hertz used electrical anaesthesia for laparotomies in dogs. To-day electrical stunning is used in bacon factories with the object of rendering pigs unconscious before slaughter. Electroconvulsant therapy (E.C.T.) is widely used in mental hospitals for the treatment of certain conditions, and recently Freeman (1948) has modified this technique to produce surgical anaesthesia for prefrontal leucotomy.

In some instances electrical anaesthesia has proved satisfactory, but there have been reports of “distorted consciousness” after E.C.T. in human subjects (Morgan, 1950), and of electrical curarization after industrial accidents (Hume, 1935); in these conditions the subject is conscious of sensation but unable to make voluntary movements. Such a condition is only appreciated when the subject is questioned after regaining full consciousness, and hence, if it occurred in animals, it would not be readily recognized.

The object of the work described in this paper was to determine the effect of the many variables of electric stimulation, and to investigate the state of consciousness of human subjects and animals after electric stunning. It was hoped thus to provide a basis for future work on electrical anacsthesia and to acquire a better understanding of the action of E.C.T.

The assessment of pain perception is a subject of great importance from both the practical and the theoretical aspect. The increasing use of curare-like drugs as muscular relaxants and basal anaesthetics (Mushin, 1951), and in conjunction with electro-convulsant therapy (E.C.T.), has made the orthodox tests for depth of anaesthesia unreliable because they depend on the activity of voluntary muscle. E.C.T. itself (Morgan, 1950) and industrial electrical accidents (Hume, 1935) have given rise to unusual states of consciousness which cannot be fully understood until more is known about the way in which electric shock affects the central nervous system. On the theoretical side many explanations of the essential features of a state of consciousness have been given, but none of them accounts completely for all the observed phenomena; investigations designed to improve methods of assessment should provide useful information which, when correlated with that from other fields, may ultimately lead to a better understanding of the conscious state. The object of the experiments described in this paper has been the development of tests which will indicate the level of consciousness, and in particular the appreciation of pain, when the voluntary muscles are paralysed.

Pain and fatigue, subjectively experienced, are two of the commonest complaints made by patients suffering from a variety of psychoneurotic and psychotic disorders. Neither phenomenon has so far been adequately studied with the available objective techniques, and the present paper embodies results of preliminary experimental investigations of fatigue and pain tolerance, together with a review of some of the clinical aspects of the problem.

In psychiatric disorders pain rarely produces overt signs which allow the observer to judge its severity, and the excruciating pain complained of by some patients appears to be accompanied by much less emotional reaction than, for example, the pain experienced by the normal individual after a burn, a crushed finger, or an abdominal catastrophe.

The evidence for somatological differences between various types of schizophrenia and its different stages of severity or chronicity is still scanty and often contradictory. The present investigation mainly concerns itself with endocrinological factors. Kraepelin, already, suggested disturbances in the endocrine system. The incidence of schizophrenia in different age-groups, especially its steep rise at puberty, reaching its peak at 20 in men and 25 in women and the rapid decline of its occurrence after these ages (Haas, 1938), has for a long time pointed to the sex steroids as an important factor in the pathology of this disorder. Hemphill et al. (1944, 1945, 1948) found an atrophy of the testes in many cases of schizophrenia, and considered the severity of the testicular change to be proportional to the severity of the psychosis. They suggest that the testicular lesions are not the cause of schizophrenia, but probably effects of the “pathogenic process” and related to hypothalamic or pituitary function. In confirmation of these findings Hoskins and Pincus (1949) observed the output of androgen in schizophrenics to be significantly lower than in normal men. Sears (1937) made similar observations in females, and found that the blood-œstrin level of female schizophrenics was much lower than in normal women. Possibilities for primary endocrinological factors suggest themselves; the “pathogenic process” can, however, still be primarily a psychological “stress” in this new constellation or a combination of both, or the effect of another central disturbance. Some of our somatological findings can, therefore, tentatively be interpreted as related to or identical with the primary stress or others only as secondary correlates or results, though the present state of our knowledge does not yet allow a final decision as to what is primary and what only secondary. Recent evidence, on the relationship of sex hormones and insulin (Houssay, 1951) suggests that oestrogens have a “sensitizing” and androgens a “desensitizing” effect. An investigation into the insulin sensitivity in clinically different schizophrenic groups and the two sexes expressed in the amount of insulin needed to produce a hypoglycaemic coma should, therefore, throw some light on other endocrinological mechanisms.

A study of the effects of E.C.T. on mental efficiency and retentivity has already been published (Hetherington, 1952). The present paper reports the effects of E.C.T. on drawings made by the same group of patients. Workers such as Prinzhorn (1922), Maclay, Guttmann and Mayer-Gross (1938), Anastasi and Foley (1943), Martin and Weir (1951) and Raven (1951) have been concerned with analysing unrestricted or “free” drawings of widely varying nature. Other workers, such as Burt (1921) and Goodenough (1926) have used restricted drawings usually of “a man” more specifically for the estimation of intelligence. Anastasi and Foley (1941) have reviewed the work done with the drawings of abnormal people, and have drawn attention to the lack of control groups, the rarity of quantitative assessments, and the danger of over-interpretation of the drawings on the part of observers. In order to meet these criticisms, patients' drawings have been compared in the present paper with those of a group of normal untreated people, assessments of the drawings being limited to quantitative measurements of area and position on the page, or to subjective judgments of consistency of style undertaken by several observers working independently.

THE present paper offers a brief summary of work which has been published in German journals dealing with the prolongation of induced convulsions. In the course of my experimental research the following phenomena were demonstrated:

1. (1) Continuousconvulsionslastingup to oneand a half hours were produced by the administration of oxygen and adrenaline, preceded by the injection of phenyl-methyl-aminopropane.

2. (2) Prolonged convulsions of 33 minutes were produced by the intravenous injection of 2 ml. of a io per cent. metrazol solution and continuous oxygen in suffiation.

3. (3) Isolated continuous convulsive activity of the cerebellum was produced lasting 30 minutes after cessation of respiration and of all cortical electrical activity. This was achieved by continuous insuffiation of oxygen together with the injection of adrenaline and strychnine.

4. (4) Activation of a prolonged convulsion up to 11 minutes, without further electric stimulation, was effected via the thalamus by the injection of adrenaline after administration of phenyl-methyl-aminopropane and continuous oxygen in sufflation.

The study of eye disorders in maladjusted children plays an interesting and important role in the investigation of psychosomatic problems of child psychiatry. Eye diseases in maladjusted children are frequently caused or aggravated by psychogenic factors. They are also sometimes connected with neurological disorders.

In determining the parameters of structure and function in the group of patients designated as schizophrenic, increasing stress has been laid on endocrinal function. A great deal of work is being done to clarify adrenocortical function. We are about to begin similar studies in respect to thyroid responsivity, using radioactive iodine as an indicator. The present report deals with a third aspect of the endocrine system.

The present study was undertaken to relate testicular changes such as those reported by Hemphill, Reiss and Taylor to adrenocortical and thyroid responsivity.

IN a previous paper (Bullock, Clancey and Fleischhacker, 1951) an attempt was made to separate schizophrenic reaction syndromes, due to diagnosable and often successfully treatable disease of known etiology, from idiopathic or cryptogenic schizophrenia. It was shown that the criteria of idiopathic schizophrenia are—

1. (1) Positivey : (a) Mentally, the classical symptoms of inadequacy and inappropriateness : of thought (paralogia), of affect (parapathema), to which one may add of volition (paraboulema), usually accompanied by hallucinations, paranoid ideas, etc.

   (b) Physically, a slightly pathological C.S.F., due essentially to an increase of the globulin fraction.

2. (2) Negalively : the absence of generally acknowledged organic disease of the brain, or any physical disease which is known to produce such disorders of the central nervous system or the C.S.F., as mentioned under (i).

A search of the literature has not revealed a report of the depersonalization syndrome occurring in identical twins, although Palmer (1946) published a report of twins in which one patient was described as suffering from “all round loss of interest with some depression…. His thoughts … milled round in a ceaseless turmoil concerning his loss of contact with people and things. There was some complaint of unreality and loss of sexual desire…. His condition was one of distressed perplexity. The illness had come on gradually.” The second patient had “tried to get his twin brother to ‘pull himself together,’ when one Saturday he became intoxicated and for a wager attempted bestiality. He woke up next morning feeling unutterably guilty and depressed, and rapidly developed feelings of unreality. His compelling symptom was the fear that his mind was disintegrating.”

These cases appear essentially depressive and progressed to a woeful, hypochondriacal state six years later.

The effective teaching of Psychiatry to medical students remains a formidable problem for many reasons apart from the actual methods employed by the teacher. Allocation of adequate time to the subject, the attitude of other teachers and students towards it, the facilities provided by local hospitals, clinics and other institutions alike contribute to the difficulty in establishing Psychiatry as a major subject within the medical curriculum. It is with the problem of teaching method alone that this paper wishes to deal: first to outline the inherent difficulties commonly encountered; secondly to describe the design of structures and equipment found useful in overcoming these difficulties in some measure; and thirdly to point the way for possible future development.

Because of the professional and lay interest in the potential value of glutamic acid in the treatment of mental deficiency the present study has been conducted.

From the section of Lennox Castle Institution, which is devoted to the training and treatment of Male Juvenile Mental Defective Delinquents, 30 patients were chosen. Half of these were treated with glutamic acid and half used as controls.

The analysis is based upon comparison between experimental and control group rather than between paired individuals. As may be seen from the table, the two groups are very similar. There is no significant difference in the age, intellectual capacity, social background or environment.