The differential diagnosis of a presenting symptom is usually to be found as a section of an article on a disorder in which the particular symptom is common. Thus one learns a great deal about the widely different pathological processes responsible for epigastric pain in a description of peptic ulcer, and much about headache in descriptions of cerebral tumour or migraine. Amnesia is peculiar in this respect in that succinct expressions of its differential diagnosis are rarely found in the description of individual disorders.

Psychosurgery consists in surgical operation on the anatomically intact brain for the purpose of relieving mental symptoms. It was first devised and named by Egas Moniz, the distinguished Portuguese neurologist, essayist and diplomat, following the Third International Neurological Congress in 1935, at which time a remarkable symposium was offered on the functions of the frontal lobes (1). Approximately a year later Moniz (2) published his monograph detailing results in his first twenty cases. We began our work in the Fall of 1936, reporting our experiences in preliminary fashion several times, later bringing them together in a monograph (3), presenting the “results” in 80 cases. Since that time we have persistently followed up these cases as well as all subsequent ones, and now, with a series of 204 cases in all, we are able to discuss the adjustment of 154 living patients over a period ranging from six months to seven years.

The observation of cases of narcolepsy does not to-day constitute a rarity worthy of notice. There are references in the literature to some hundreds of these cases, and we ourselves possess several observations which do not differ from the type described in monographs and text-books. However, in recent months there has come to our notice a case which presents rather peculiar characteristics. The truly remarkable amount of detail in the clinical picture, the rapid evolution of the disease, its combination with a syndrome of very marked oneiric manifestations at night, make the case in question worthy of note.

In spite of the voluminous literature on the shock-therapies which has appeared in recent years, there is as yet little unanimity of opinion among psychiatrists as to the value of the anoxic and hypoglycaemic shock-therapies, and their indications, possible scope and limitations in the treatment of psychoses. Most potent in perpetuating this unsatisfactory state of affairs have been the too-rigid reliance on masses of statistics in evaluating results of treatment, the oft-repeated statement that the therapy is purely empirical, and last, but not least, the unfortunate publicity which it received at its inception, the result being that lately there has been a tendency to discredit the therapy, and a growing scepticism as to its efficacy.

It is generally known that in recent years there has been a considerable increase of the elderly population. In addition, we assume that unless the birth-rate rises again, an increasing proportion of the population will be found in the involutional and senile periods of life. This development has already begun; whereas in 1901 7.6 per cent. of the population of Scotland were over 60 years of age, the percentage in 1941 has been estimated at 13.0. Men are less long lived than women, the figures being 6.6 and 8.-6 in 1901, and 12.1 and 13.8 in 1941.

The following report is based on 150 men treated in hospital, and 300 patients, 50 of whom were women, seen at a diagnostic and advice centre.

As a rule, stresses and precipitating factors were more obvious or easily discoverable than in civilian life, adverse situations were more superficial, diagnosis and treatment were easier. Anyone who has conducted civilian clinics finds the change-over comparatively easy. Nevertheless, much of what follows is applicable to civilian work.

Paranoid delusional reactions have seldom been reported in chronic encephalitics, in contrast to the commonly occurring schizophrenia-like reactions. Apart from the cases described by Kwint (1), Ostmann (2), McCowan (3, 4), and a reference by Neustadt (5) to an undescribed case, there seem to be few, if any, references in the literature until a recent paper by Brody and Freed (6) describing a case where obsessive ideas became temporarily converted during oculogyric crises into a paranoid condition. The present case therefore seems worth putting on record, the more so in that the patient's unusual intelligence helped to throw some light on the relationship between oculogyric crises and post-encephalitic mental disorder, a subject which has been discussed by Stern (7), Jelliffe (8), and more recently by Wexberg (9) and by Brody and Freed (6).

The case about to be described presented a problem of some complexity in neurological diagnosis. The attempt here made to unravel the problem is set forth with the full realization that some quite different explanation may be the true one. The true explanation, however, is incapable of proof and the view offered here is only suggestive, though of some interest because of the rarity of lesions of the superior cerebellar peduncle in man.

Two previous publications have been devoted to the behaviour of various reflex phenomena, and of the grasping phenomenon in particular, during the post-convulsive stage of the electrically produced seizures in man (1942, 1943).

This paper deals with eye movements in the shock procedure, and experiments planned to influence these movements.

Parotid gland secretion is one of the most easily observable manifestations of autonomic activity, and a study of the secretion of this gland should be helpful both in the elaboration of the theory of autonomic activities and perhaps also in practical diagnosis (1, 2, 3). Strongin and Hinsie have shown that whereas normal subjects secrete on the average.07 c.c. per 5-minute period, varying from 02 c.c. to .15 c.c., none of a number of manic-depressive patients studied by them secreted more than .01 c.c. per 5-minute period (4, 5).

“Effort syndrome” is a comprehensive term applied conveniently to a group of conditions not apparently due to organic disease, characterized primarily by effort intolerance and manifesting breathlessness, palpitation, left chest pain and a subjective feeling of fatigue on even mild exertion. Vegetative lability on emotional excitement, e.g. palpitation, sweating, giddiness, etc., are described by the patient and may be objectively observed. We have found the simplest and most convenient classification of E.S. patients to be into (a) primarily constitutional, and (b) primarily neurotic groups. In the former (Group 1) the patient has had a poor physical endowment since earliest recollection, to which he has responded in a neurotic manner. In this sense there is a psychological aetiology, but the constitutional factor is the basic one. In the primarily neurotic group (Group 2) there is a definite psychopathology and the usual factors determining a neurosis apply: constitutional physical inferiority, if present, colours the whole picture, but is of only secondary importance. The whole problem has been studied in some detail in the E.S. Unit at this hospital, where more than 2,000 cases have been treated since the end of 1939 (Guttmann and Jones, 1940; Wood, 1941; Lewis, 1941; Jones and Lewis, 1941; Jones and Scarisbrick, 1941, 1942 and 1943).