Few mental diseases have attracted the attention of medical men working in outlandish parts of the world more than Latah. This is due, not only to its intrinsic interest, showing as it regularly does the unusual symptoms of echolalia, echopraxia, and automatic obedience, but also to its remarkable geographical distribution. This illness was described by travellers to the Malay Archipelago in the latter part of the nineteenth century, but very similar reactions were later found to exist in other lands, known to the native peoples by other names. The term “Latah,” however, is the best known, and as the common features between these various reactions became apparent, it has been used as an inclusive name for them all. It is to-day employed with much the same connotation in the French, Dutch, Italian, and English literature, but the discussion of its nature betrays inadequate understanding, attempts at its nosological classification remain unsatisfactory, and speculations as to its aetology continue to be somewhat fanciful.

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.

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.

In the first place I would like to thank the Association for the great honour they have seen fit to do me in appointing me their President for the ensuing year. It is indeed a great honour and a sobering experience to occupy a presidential chair which has been filled in the past by such illustrious psychiatrists as Conolly, Maudsley, Crichton-Browne, Clouston, Mercier and Mott, to mention only a few. Not least amongst these names, one day I am sure will rank that of my immediate predecessor, Dr. Drury.

The prefrontal region lies in front of the motor and premotor areas of the frontal lobe. In Brodmann's terminology this corresponds to areas 8, 9, 10, 45 and 46 on the convexity; 11, 47 and 13 on the orbital surface; 24, 32 and 12 on the mesial surface. When speaking of selective prefrontal surgery, we mean topectomy or cortical undercutting or partial leucotomy of one or several of these areas.

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.

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.

Since the demonstration of increased sympathetic activities during insulin hypoglycaemia by Cannon, MacIver and Bliss (1924) the assumption has been current that hypoglycaemia also increases the concentration of circulating adrenaline, and repeated attempts have been made to verify this experimentally. Brandt and Katz (1933), using the perfused rabbit ear, the isolated rabbit ileum and the enucleated frog eye as test objects, found that human blood possessed adrenaline-like activities during hypoglycaemia, while control blood was inactive. Meythaler and Wossidlo (1935) reported that the blood of subjects injected with insulin caused an increased vasoconstriction of the perfused rabbit ear and, more recently, Meythaler, Lobenhofer and Haggenmiller (1951) found that the response varied according to the constitutional type of the subject. Heilbrunn and Liebert (1939), however, observed no uniform effects when they tested the blood of patients undergoing insulin shock therapy with the frog perfusion technique; while there was a rise of adrenaline-like activity in some patients, others showed a fall and some failed to show any definite pattern. The results of Tietz, Dornheggen and Goldman (1940) and of Tietz and Birnbaum (1942) who used Shaw's colorimetric method indicated little change in the first two hours after insulin injection, but in the later stages of hypoglycaemia there was a more consistent tendency towards an increase of concentration. The proportion of adrenaline in the chromogenic material estimated by Shaw's method increases during hypoglycaemia, according to Raab (1943). Kalaja (1942), with a fluorimetric method, also found an increase of the blood adrenaline level after insulin injection. On the other hand, Richter (quoted by Jones, 1939) who used the method of Shaw came to the conclusion that adrenaline was not present in significantly increased concentration in arterial blood during those stages of hypoglycaemia when the clinical picture suggested the possibility of adrenalinaemia.

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.

During the last eight years the E.E.G.'s of over 100 persons awaiting trial on charges of murder have been examined, at first at Sutton and since 1947 at the Maudsley Hospital. While a few cases were seen during the war, the majority of these prisoners have been examined since the end of hostilities and about 50 of them between 1948-1950. It is difficult to assess to what extent this group constitutes a cross-section of the murderer population. During the four years 1945-48 inclusive some 300 prisoners were committed for trial at Assizes over the whole country on the charge of murder and this is the stage at which the majority of our subjects have been examined. Some 50 prisoners were examined during this period so that approximately one-sixth of all cases have been seen here. There were no formal criteria of selection, which was usually made by the prison medical officers, but inevitably there has been a greater concentration within the group of individuals suspected of epilepsy or brain disease. Nevertheless, in the last two years the majority of prisoners accused of murder in the London area and home counties have been examined. At the time when the examinations were made, we were supplied in each case with full clinical details and some information regarding the alleged crime by the prison medical officer. By far the largest number of such prisoners has come to us from Brixton Prison. We are greatly indebted to Dr. J. C. Matheson, Dr. Hugh Grierson, Dr. F. H. Taylor, as well as to medical officers of other prisons throughout the country, who have given us all the information available and have collaborated with us in an invaluable way in our investigations.

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 word “oecology “was coined by Hacckel in 1869, and the study of the complex interactions between organisms and their environment led to fruitful results first in botany (at the beginning of the twentieth century) and later in zoology. In 1935 Bews formulated the principles of human ecology, but the precise boundaries of this discipline (as Banks (1905a) calls it, since it cannot be called a science) are still not the subject of any general agreement. Its dictionary definition as “that branch of biology which deals with the relations of human beings to their surroundings, their habits and modes of life,” although simple for the purposes of formulation, is probably too diffuse in practice. On the other hand, Miller (1950), in suggesting that the ecological study of disorders should be confined to their distribution in the purely demographic sense, seems unduly to restrict its application. There is a tendency among American ecologists (who have been the pioneers of this subject) to take a middle course. Park (1936) conceives of human ecology as the study of the community in terms of the competitive forces which mould it, as opposed to the cultural forces which make for social co-operation. Similarly, Faris (1944) distinguishes the ecological order, which arises automatically and unintentionally out of the struggle for survival, from the cultural order, which is based on mutual affection and sentiment.

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.