The aetiology and significance of schizophrenia in childhood is still so obscure that it is profitable to analyse fully every case that is diagnosed. In the United States of America, where cases appear to occur more frequently, the picture of full-blown childhood schizophrenia has been well drawn by Bender, Kanner, Szurek and others, but the descriptions are more of the whole forest and the details of the individual tree are missed in the whole. Excellent individual studies certainly are made, but the significance is often not understood, as if the workers were more used to macroscopic than to microscopic studies, but an unforgettable demonstration of the gross pathology and clinical picture of childhood schizophrenia is given at the Langley Porter Clinic in San Francisco. The over-all impression is one of emotional fixation at the infant to toddler level. In a variety of cases all stages may be shown from the oral to the anal level of erotism, from the delight and practice of bodily movements at rest and in space, to the experiments and flights in fantasy of the later period. Play is also at the toddler or earlier level—one child of ten years came offering everyone cups of imaginary coffee to drink—and there is the same lack of team spirit, the same failure to make groups of more than two for any length of time, the same mischievous exploratory tendency, the same perseveration tendency with any trick, the same range of comfort mechanisms from thumb-sucking to rocking and masturbation, the same range of speech from babble to sentences as is found in any nursery and nursery school, although the chronological age-range may be five to fifteen years instead of six months to five years.

The inadequacy of verbal development is the most striking handicap to the analysis of children. In the young child, under seven years, many concepts such as “happy,” “sad,” and “worried” are frequently not recognized at all; the child's very vocabulary is too limited for expressive purposes. Even as late as pre-adolescence the child may fail to correlate its inner experiences with its vocabulary. Besides the limitation of vocabulary due to intellectual immaturity there is also the Super-Ego's restraining action on what may be expressed verbally, in cold blood, and the younger the child the greater is this restraint. Most children, however, given an adequate medium other than words, are richly expressive of themselves but, unfortunately, it is now the adult who is inadequate and frequently fails to understand the language that the child is using, or, understanding it, cannot express himself in it. He “interprets” for the child in the more adult language of words, and sometimes even at a more adult level of erotic and emotional development than the child's. When this happens the child usually demonstrates its inability to correlate the inner experience which it is expressing in its own language with the adult's verbal interpretation. It either takes no notice or is frankly puzzled, or gives up its expression as if stunned by the unexpected.

Recent research from psychological, psychiatric and social viewpoints has emphasized the importance to the whole community of the aged population, and has stressed in particular that the changing proportion of aged to working populations is bringing with it problems of great urgency.

The problem of differentiating, in patients of the pre-senile age group, the degree and quality of intellectual impairment that is due to depression from that which is brought about by some organic, cerebral deterioration is one of some practical importance. It is, in fact, as Henderson and Gillespie (1950) stress, an important point to determine with regard to the prognosis of depressive cases of this age” whether or not there is any complicating organic process causing a failure of memory and efficiency. If such is present then the prognosis must be viewed much more gravely than would otherwise be indicated.”

Electrical stimulation of different areas of the human brain has hitherto been confined to experiments with the brain in situ, in living subjects. It has been carried out while the brain received its blood supply from normal sources. By chemical analysis of the arterial and venous blood and measurement of its rate of flow, information has been obtained on how metabolic changes in the brain vary with changes in its activity. However, these conditions can give information only about gross biochemical changes associated with stimulation; they are cumbersome, and would not indicate abnormal reactions in small areas. Also, they detect differences only in substances which are actively exchanged with the blood stream.

In the first part of an experimental study of learning impairment (Hall and Crookes, 1951) the present writers described some of the distinctive features of the performance of schizophrenic and organic patients on two learning tasks. Brief reference, by way of introduction, was also made to studies of learning efficiency in psychoneurotic patients which were carried out by Zangwill (1943, 1946) and Trist (1941). These writers, and also Davis (unpublished), noted particularly some of the reactions and types of failure that neurotic patients sometimes show, with special reference to the Rey performance test. Certain reactions to the test were felt to be characteristic, for example, of patients with anxiety states or hysterical reactions, although none of the writers had carried these observations further or confirmed them experimentally.

Temporal arteritis, also called giant cell arteritis, or cranial arteritis, was first described in 1932 by Horton and Magath. This syndrome is caused by a reversible inflammation of the cranial arteries, especially the temporal arteries (which are visibly inflamed), causing headache, mental and neurological disturbances as well as general toxic signs, and almost always occurring after the age of fifty-five years.

Pathology.—In the arteries involved there is a subacute inflammation of the adventitia and media with focal necrosis of the media, fragmentation and destruction of the internal elastic lamina with gross hypertrophy of the intima, often leading to occlusion of the vessel. In many cases giant cells are found in the media. Besides the cranial arteries other vessels are sometimes involved, e.g., the carotids (Scott and Maxwell 1941; Gilmour 1941), subclavian, coronary and femoral arteries (Cooke et al., 1946), post-auricular (Dick and Freeman 1940).

Aetiology is unknown. There is no evidence of tuberculosis or syphilis. A low-grade bacterial or virus infection of the arteries has been postulated, but repeated bacteriological examinations of the biopsied arteries have failed to isolate any organisms. The predilection which the condition shows for the temporal and cranial arteries is unexplained.

Somatic disturbances in schizophrenia include metabolic, circulatory and endocrine changes frequently associated with disorders of the pituitary gland and adrenal cortex. Depression of the metabolic rate is often severe (Hoskins, 1932), the systolic blood-pressure is sometimes as low as 80 mm. Hg (Hoskins, 1934; Rheingold, 1939; Shattock, 1950), and the pulse pressure only a few millimetres. Peripheral vascular deficiency and atrophy of the tissues (Bleuler, 1920; Mapother, 1924; Minski, 1937; Shattock, 1950), asthenia and various cutaneous changes are common; amenorrhoea is almost the rule.

It is remarkable that these disturbances are reversible, and that they are relieved or greatly alleviated during mental remission. Physical health is restored during a spontaneous remission, and a gradual improvement can be observed during a course of insulin comas. Sometimes a dramatic recovery follows electroconvulsion when this initiates a mental remission; somatic improvement is then rapid and the vascular deficiency may be relieved within a few hours (Shattock, 1950). Unfortunately these remissions are often brief, and as relapses become more frequent after repeated treatment, physical and mental deterioration may be noticeable a few days after the initial improvement. The point of interest is a concordance of physical and mental changes, and not the therapeutic value of E.C.T. used as an adjunct to insulin treatment or as a means of moderating extreme restlessness in chronic patients.

The intelligence, as measured by standard tests, ceases growing after about 14 or 16 years of age, and slowly decreases from about 25 or 30 years of age (Wechsler, 1945). The sex glands are developing as the intelligence ceases to develop.

In view of these observations, consideration was given to the possibility that the defective developed mentally to a degree below the normal because too great a quantity of the appropriate sex hormones was circulating in the blood stream. In consequence, the opposite hormone was administered, stilboestral being given to males and pernandren to females.

The Colour-Form Sorting Test was described by Weigl (1927) as one of a series of investigations into the nature of the psychological deficit resulting from a cerebral lesion. The material consists of 12 pieces: four squares, coloured severally red, yellow, blue and green; four circles, similarly coloured; and four equilateral triangles, similarly coloured (Fig. 1). They are presented in a random arrangement to the patient, who is asked to group them according to any similarity he sees; and when he has sorted them according to one principle, is then asked to sort them according to another.

Other problems involving sorting were presented in Weigl's study, and have been used in a number of investigations, particularly of the effects of frontal lobe lesions. Rylander (1939) found that his group of patients with frontal lesions differed significantly from the normal controls in the number of principles found for grouping 15 objects. Halstead (1940) used 62 common objects, and also found that patients with frontal lesions tended to find fewer principles for sorting than did patients with cerebral lesions located elsewhere. Subsequently Halstead and Settlage (1943) developed a mechanized grouping test, using geometrical figures: three patients, with frontal lesions, and one with a left occipital lesion, made many more errors than did the normal controls; while a patient with a right occipital lobectomy and one with a left parietotemporal lesion performed normally in this respect. Finally Halstead (1947) found that, of his group of ‘indicators” of cerebral damage, a similar test (No. 2) not only differentiated reliably the patients with cerebral lesions from the normal controls, but also gave a significantly higher error score with cases of frontal lesion.

Goldstein and Scheerer (1941) included Weigl's test in their experimental study of abstract and concrete behaviour; and Trist and Trist (1943) and Brody (1943) noted impairment on this test in cases of general paralysis and the presenile dementias.

When electroshock is given, there is generally a rise of blood-pressure for a time. It is therefore stated in various text-books that the treatment is contra-indicated in cases of hypertension. Even premedication with thiopentone and curare does not always succeed in lowering the pressure to a safe level. It is also known that the initial rise in pressure may be followed by a subsequent compensatory fall, so that any drug which prevents fluctuations of arterial tension is likely to be of value. Etamon [tetra-ethyl ammonium chloride (T.E.A.C.)] lowers the blood-pressure by acting on the synapses of the sympathetic nervous system.

Many hospitals have found that electronarcosis is a valuable adjunct to treatment, as it is frequently successful when simple electroshock has failed. On many older patients, however, in whom this treatment is especially useful, the rise of blood-pressure can be very marked; and even forward placement of the electrodes does not always avoid this complication.

At the West London Hospital it was therefore decided to try out the effect of Etamon (Burroughs Wellcome). The bromide salt has the same effect. This drug has been used to lower the blood-pressure in hypertensive states, but there are certain disadvantages in its prolonged use for this purpose. Its administration, however, to combat a temporary rise of blood-pressure lasting 20 to 30 minutes is without any ill effects at all.

Mr. Gladstone, with that candour which a great Statesman can afford, once said, “Government is a rough business, and the results are most unsatisfactory.” Unfortunately no great psychiatrist has described the present state of our knowledge and treatment of schizophrenia in an equally robust phrase; but surely, “rough business and unsatisfactory results” would not be an unfair summing up ?

We have now known of this illness for nearly half a century, and yet our understanding of it is slight and our useful information scanty. This is not because we have been idle, but because our efforts have been poorly rewarded. Thousands of papers are written every decade; tens of thousands of observations are made; there is no lack of opportunity for studying patients when about one hospital bed in five in this country is occupied by a schizophrenic, yet we are still entirely ignorant of the cause of this disease. There are, it is true, numerous theories, but none is generally accepted. We have one form of treatment, deep insulin, which produces remission of symptoms in some cases and what seems to be a cure in others, but even the value of this treatment is hotly disputed. Because deep insulin is a purely empirical procedure the psychiatrist is always tempted to become preoccupied with details of technique so that he forgets, or at least becomes less aware of our fundamental ignorance.

Mental deficiency has been defined by Tredgold as a state of arrested or incomplete development of the mind. Numerous scientists have for long endeavoured to ascertain the cause or causes of this frequent abnormality. The protagonists of one school of thought made exaggerated claims that the great majority, if not all cases, were due to hereditary factors. Other investigators were able to demonstrate that certain special types of mental defectives owed their deficiency to agents acting after fertilization, and so came to the conclusion that genetic elements were only concomitant and not primary causative factors in many, if not in all types of defectives, and that research on these lines should eventually establish extrinsic causation in all these cases.

Thus one has gradually come to distinguish between two main groups of mentally abnormal individuals; those in whom endogenous or hereditary factors could be proved or at least suspected. (Tredgold speaks of primary aments, Strauss of endogenous types, and those in whom exogenous noxious influences could be demonstrated or suspected, and whom Tredgold termed secondary aments, Strauss calls exogenous types.) According to Tredgold and many other investigators, from between 70 to 80 per cent. of all defectives are to be found in the first group, while roughly 20 to 30 per cent. belong to the second. Penrose's figures in support of a hereditary causation are even higher.

Three years ago at the last International Congress of Psychology I reported on a preliminary investigation of personality changes after the usual standard prefrontal leucotomy. This investigation was carrried out on 20 neurotic patients before and three months after the operation performed by Mr. McKissock (McKissock, 1943). An extensive group of objective personality tests were chosen to define the factors of “Neuroticism” and “Introversion” as described by Eysenck (1947), which to all intents and purposes are equivalent to Cattell's (1950) factors C and F. In addition, the following intelligence tests were used: the Wechsler Scale, Porteus Mazes, and the proverbs from the Stanford Binet. The changes found provided us with some evidence in support of the hypothesis with which the investigation had been planned. This was that as a result of this type of incision in the frontal lobe there was a decrease in “Neuroticism,” a decrease in “Introversion” and a decrease in certain aspects of intelligence (Petrie, 1949a).

Since then a further 50 patients have been examined before and after operations on the frontal lobes, bringing the total to 70. Most of these were severe neurotics attending the psychiatric department of Dr. Desmond Curran at St. George's Hospital, London. Only those changes will be referred to as an alteration in personality where the probability is less than one in twenty that they could have occurred by chance.

In a paper published in the Journal of Mental Science for July, 1950, I suggested that head-banging originated in the infant's desire to reproduce the thrust of the mother's apex-beat against his head while he was being nursed on her left arm, either as a means of self-comfort or in retaliation for what he had felt to be an attack or as both combined. In the present paper I propose to analyse this infantile experience further, and to trace to some of its component elements certain other peculiarities of childish behaviour.

I shall begin by considering the case of a bottle-fed baby, that is to say, one who at every feed is held in his mother's left arm with his right temple against her left breast (and I shall suppose that the mother is not herself a case of dextrocardia.) In addition to the teat in his mouth and the milk being swallowed, such an infant feels the thrust of the mother's apex as a series of taps against his head which tend to impart to the latter a rolling side-to-side movement, he hears her heart-beat as a rhythmic lub-dup, he feels the rise and fall of her chest in respiration as a slower to and fro rocking of his whole body, and he hears the sighing rustle of her breathing beneath his ear. The sound and thrust of the heart-beat are of course louder and stronger at the limit of the mother's expirations, and indeed the tap of the apex may be felt only then. In other words, the suckling hears two separate series of interwoven unsynchronized rhythmic sounds continuing throughout the whole of his feeding times. In addition to all this, he feels the warmth of the maternal body, the steady clasp of the mother's arm, he smells the milk and the woman's body odour (sweaty, or scented by her soap and talcum powder), and lastly, he feels (and may smell) her breath as an intermittent warm breeze on his face and in his hair. The mother seldom speaks while she is feeding her baby, and the room is often quiet, mother and child being alone together. A breast-fed baby also feels smooth warm skin under his fingers, but he has the mother's heart against his head, during only half his feeding times.

The other occasions on which a woman commonly holds a child firmly against her breast are, of course, when she is trying to comfort a crying baby, or to restrain a struggling toddler from escaping to some forbidden activity. Here the child is angry and the mother herself often either anxious or angry or both, so that her heartbeat is greatly increased in force, and the furious infant feels it as a series of aggressive blows on his head, each of which is accompanied by a bumping noise.

The majority of investigations into psychological changes due to E.C.T. have been undertaken to assess the effect of treatment on the patient's memory. Sherman, Mergener and Levitin (1941), testing for retention of material assimilated on the same occasion as it had to be recalled or recognized, found no significant effect of E.C.T. upon memory. Zubin and Barrera (1941) found that E.C.T. removed the saving that would otherwise have occurred between learning and re-learning paired associates. They also reported that the effect of treatment on the recognition of material was less severe than on its recall, and this was confirmed by Mayer-Gross (1943).

The present paper reports psychological changes which have been found to take place during a course of treatment with E.C.T. as well as before and after. The investigation is a development of a pilot experiment undertaken with Dr. M. Roth which was briefly reported at the International Congress of Psychiatry, Paris, 1950.