The adolescent psychoses are amongst the most rewarding subjects for study in all psychiatry, not only on account of the considerable clinical interest of these patients, but because no other group affords the psychiatrist quite such an advantage by reason of age alone, an age that covers the peak phase in maturation. The juvenile is young enough for childhood environment to be vividly recalled, the responses to the stresses of puberty are already evident, and in a short space of time the writing of the future adult life pattern will be on the wall. Furthermore, owing to the more likely presence of parents or guardians, sometimes lost or dead by the time one deals with adult disorders, a more comprehensive view of the hereditary influences, and a relatively adequate account of the early formative years, is generally possible.

Although pure word deafness (p.w.d.) is a well-defined clinical picture it usually occurs as part of a more complex syndrome. Almost invariably there is some degree of aphasia and as a rule other auditory disturbances, such as imperception of specific sounds including musical tones, also occur. These associated symptoms tend to diminish or even disappear in time while the deafness for word sounds usually persists in its initial intensity. In the case we describe most of the associated symptoms, especially the aphasia, soon abated leaving an almost pure word deafness. Subsequently this too improved slowly and because of the partial recovery we were able to obtain data which are rarely available in these cases.

Historical Background

Asthma is an illness which has puzzled our profession since earliest times. Each generation has based its concept of aetiology on current concepts of disease, so that delving into its history shows a colourful pattern of widely conflicting views.

Early in this century Osler (1910) is in favour of a nervous cause, though he pays little attention to treatment on psychological lines. After that date there is a procession of changing viewpoints.

In the second decade, anaphylactics, according to Conner (1917), have cracked the hard core of the aetiological riddle, but Eppinger and Hess (1917), writing of vagotonia, correlate this with the asthmatic attack.

Freeman (1921) writes of precipitating nervous reflexes. Bray (1934) is convinced that the allergist holds the key to solution. There is emphasis on allergic diathesis and an hereditary asthmatic constitution.

Wittkower (1935) showed that asthma might have a purely psychological conditioning. Since that time, belief in the importance of the psychological factor is still gaining ground.

The theme of the present communication arose from research of Bostock and Shackleton (1951, 1952) on the aetiology of enuresis. There emerged the concept of premature toilet training interfering with later development of urinary control. It suggested that a study of asthma in its early stages might show an interference in the normal process of respiratory and speech maturation.

As will be shown, there is a similarity, although the mechanism is more complicated.

Meratran (alpha-2-piperidyl benzhydrol hydrochloride) is a cerebral stimulant with an action not unlike the amphetamine series but differing in other respects in that it does not interfere with sleep, nor appetite, nor is its use followed by depression. It is not apparently a sympathomimetic drug, since it does not cause any marked cardiovascular pressor effects. Recent reports from America (1) have suggested that the drug is of use in treating patients suffering from depression and psychomotor retardation either due to mental illness, fatigue or a side-effect of other drugs, e.g. chlorpromazine or reserpine.

Sakel (1938a) drew attention to the difficulty of establishing satisfactory comas in a minority of patients attending for Deep Insulin therapy. This phenomenon has since been confirmed by other workers including Tillim (1938) whose patient received 500 units of insulin without the production of deep coma, by Hall (1940) who reported an instance in which 1,000 units of insulin was equally unsuccessful, by Reznikoff and Scott (1942) who described how neither 120 nor 1,000 units of insulin when injected intravenously produced any significant difference in hypoglycaemia in insulin resistant patients, and more recently by Fogarty (1953) whose case required 5,000 units of insulin for the production even of sopor. Other recorded examples of resistance to massive doses of insulin include those of Banting et al. (1938) and Tennent (1944).

Various explanations of this perverse response to insulin have been formulated, including that of Jones (1939) who proposed that resistance to insulin was both a problem of true insulin insensitivity and also of an anomalous response of the central nervous system to hypoglycaemia. Meduna et al. (1942) preferred to ascribe it to anti-insulin factors in the blood, but a more interesting interpretation derived from Freudenberg (1952) who suggested that if the effects of high insulin dosage employed in insulin coma treatment were regarded as a special instance of a stress response, then the fluctuations and differences in response could be equated in terms of the General Adaptation Syndrome of Selye. High doses were thus an index of an effective “alarm stage” characterized by a discharge from plentiful adrenocortical reserves.

Through the generosity of the South West Metropolitan Regional Hospital Board a research unit for the study of apparently deaf children with defective speech was set up in Belmont Hospital in March, 1953. The primary object of the unit is to attempt to assess by methods which will be discussed later whether children who have acquired no speech are in fact only deaf or whether they are mentally defective, emotionally disturbed, or are suffering from these or other conditions. It is an undoubted fact that some children who have never spoken and who are therefore inaccessible and who may be asocial or antisocial in their behaviour are diagnosed as being mentally defective and spend their lives in mental defective institutions. It has however already been shown in our unit that a number of these children when under observation for a period of time prove to be deaf and probably educable. If facilities were available to continue their education under specialized conditions they could no doubt make useful citizens within their limitations. Before discussing the problems associated with these children in more detail it might be as well to describe the personnel and layout of the unit.

Although Külpe (14) used only three subjects in his original experiment on tachistoscopic memory in 1904 his classification of them into colour, form and intermediate types has initiated a substantial amount of psychological research all over the world. Thus investigations into both normal and abnormal personality correlates of reaction to colour and form have been carried out in France (8), Poland (1), Italy (5), (18), Japan (17), Britain (6), (9), (16), America (4), (23), Sweden (2), (15), and Germany (20), (21) to quote but a representative sample.

The new clan of treated phenylketonurics (1) cannot be assumed to be a happy one, or one with a high proportion of well adjusted individuals. Conceding for the moment that the Phenylketonuric, if he sticks to his diet, will retain much of his intelligence, it is safe to predict that he will be miserable. One of his life's basic processes for satisfaction, his food, has been seriously tampered with, and replaced by a conflict. Eggs, milk, cheese, meat, fish, poultry, most fruit, even ordinary bread, are taboo for his table. He will consume a diet which will be cunningly prepared and flavoured, but he can hardly say that he “eats food”. His fate is that the satisfaction—and the surcease—of incorporating various articles of food does not exist for him, or only in an attenuated form.

Prognosis, the prediction of the outcome of an illness, has long been recognized as a necessary skill of a physician. Hippocrates (translated Chadwick and Mann, 1950) said:

“It seems highly desirable that a physician should pay much attention to prognosis. If he is able to tell his patients when he visits them not only about their past and present symptoms, but also to tell them what is going to happen, as well as to fill in the details they have omitted, he will increase his reputation as a medical practitioner … It is impossible to cure all patients: that would be an achievement surpassing in difficulty even the forecasting of future developments … By realizing and announcing beforehand which patients were going to die he would absolve himself from any blame.”

In addition to the reasons given by our distinguished forebear we now also require to read into the future so that we can make the best use of the limited facilities available for the sick. This is particularly true for elderly psychiatric patients for whom treatment facilities are still very inadequate. It has been suggested (Cook, Dax and Maclay, 1952) that mentally ill elderly people should by preference be admitted to short-stay units attached to general hospitals for the assessment of prognosis and probable response to treatment. They suggested that a 3-4-months stay might be necessary. Experience in a diagnostic outpatient clinic (Norris and Post, 1954) led one of us (F.P.) to believe that it should be possible to classify patients according to the best method of dealing with them in a shorter time even than the six weeks recommended by the B.M.A. Report (1947). The present study was designed to test this belief. Our hopes were only partly fulfilled, but a post hoc analysis of our original data, in conjunction with the known results of the follow-up of cases, has suggested that with more knowledge of the factors influencing prognosis over a short term, much more accurate forecasts could have been achieved. The second half of this paper is devoted to a discussion of these factors. A preliminary report was given at the Third International Congress of Gerontology (Kay et al., 1954).

The significance of the electro-encephalographic variations found in old age is not well defined and hence the value of this form of investigation as a prognostic measure is doubtful. Apart from a few papers such as Mengoli (1952), Mundy-Castle et al. (1954) and Obrist (1954), most of the published work contains no reference to findings obtained from a control series of persons of similar age and not suffering from a definite disability. This absence of definite criteria in respect of the EEG findings in records taken from apparently healthy elderly persons is important both as regards clear-cut abnormalities and also in reference to minor variations of doubtful significance.

This paper reports part of a research into the relationship of certain aspects of mental functioning and the psychiatric illnesses of old age. One of the apparent deficits of function to which much importance has been attached is “memory impairment”. This is commonly considered part of various clinical syndromes, especially of the “organic” mental disorder of the senium. The measurement or estimation of memory function is, therefore, thought to be of considerable importance and most clinicians working with elderly patients use some kinds of tests which purport to measure it. There are, however, some points of conflict between clinical usage and the evidence of objective investigations in this area. It has never, for example, been demonstrated in relation to memory assessment that “memory” as such, can usefully be considered as even relatively independent of intelligence in young normal adult subjects (Eysenck and Halstead (1)).

Although described as far back as 1898, the Ganser state is still a subject of controversy and causes discussions regarding its existence as a clinical entity, its psychopathology and its incidence. Lately, Goldin and Macdonald (1955) endeavoured to clarify the meaning of the Ganser state after a critical review of the literature. They provided an illustrative case report with some hitherto unreported features and psychological test results. Although their paper presents a wealth of valuable material, there are still some points which need further discussion and elucidation.

The association of abnormal low frequency rhythms in the EEG with intellectual deterioration in old age has now often been described, but there has been no clear indication of a quantitative correlation between the degree of abnormality of the EEG and the severity of the deterioration. The present paper describes an attempt to explore the possibility of the existence of such a quantitative correlation.

While to no one can the present state of child psychiatry afford grounds for complacency, there is at this time an awareness of shortcomings, a lively sense of self-criticism and an urgency for advance in one direction or another that does give some grounds for optimism. I have thought it profitable at the present time to attempt to survey the scene.

I want to thank you, Mr. President, and the members of this Society for the privilege of appearing before you.

You are all familiar with the fact that headache, dizziness and mental disturbance occasionally persist for a long time after closed head injuries. These symptoms are usually grouped together under the title, “Postconcussional Syndrome“. The question whether or not there is an organic lesion at the root of this syndrome has engaged many minds for many moons. I think the majority of observers would agree with the text which I have taken for this discourse. You will find it in the tenth chapter of the last book of Mayer-Gross, Slater and Roth, page 408. There it is written, “Although predisposition and psychological factors would appear to play a predominant role in its causation, the probability is that some degree of organic change plays its part in most cases.”

In previous papers (Roth and Morrissey, 1952; Roth, 1955) evidence for the importance of affective psychosis in old age was presented. It was shown further that in some half of those admitted after the age of 60 no attacks had occurred before this age, and that no new aetiological factor such as cerebral degeneration was associated with these cases of late onset (Kay, Roth and Hopkins, 1955). The problem is to elucidate why it is that defences against illness effective throughout most of these patients' lives prove inadequate in old age. Now in the study just referred to, a tendency for physical illness to be commoner in patients having their first attack after 60 was noted. A more detailed analysis of the incidence of physical illness in the two groups has therefore been carried out in order to investigate its possible aetiological role in old age affective disorder.

There have been some indications in recent literature (Naidoo, 1956) that reserpine influences the kind of fit that patients have with E.C.T. The first time this came to our notice was a few months ago when we noticed that a patient who was receiving 9 mg. of reserpine daily took an unduly long time to resume breathing after her fit. However, she also had Parkinsonism, and we were using succinyl choline and intravenous anaesthetic, so we thought that perhaps this was a Parkinsonian idiosyncratic response to reserpine and succinyl choline (Ferguson, 1956). Since then, in chronic psychotics who have been having quite large doses of the drug over a long period, we have been struck by the apparent delay in resuming respiration after E.C.T. given “straight”, i.e. without relaxants. There have been alarming reports of collapse, even death in one instance from America (Foster and Gayle, 1955).

My purpose in this paper is to analyse the attitudes of people toward their own hallucinations and the attitudes of other people toward people who have hallucinations in our own and other cultures. It will, however, be helpful first to present a phenomenological classification of hallucinations.

The pharmacology of chlorpromazine (Anton-Stephens, 1954; Hopkin, 1955) and its use in psychiatric practice (Garmany et al., 1954; Elkes et al., 1954; Charatan, 1954; Labhardt, 1954) have been described in several recent papers. The present paper briefly describes a controlled experiment on the use of the drug in a group of chronic disturbed schizophrenic patients, the object being to introduce as few variables as possible into the experimental situation, with a view to making the results as objective as is ever possible in a psychiatric investigation.

It is often said that the Disorders of Affect are the most commonly encountered psychoses and it is, of course, depressive illness which accounts for the large majority of such disorders; nevertheless Mania and Hypomania present as great a problem. As great because from the medical point of view treatment is less certain and less satisfactory, and socially because the manic, and even more the hypomanic, patient seems capable of doing more harm to his family and home by his ill-judged actions and schemes than almost any other person. He seems, too, to have a singular affinity and attraction for wasters, ne'er-do-wells and psychopaths who assist all too readily in the disposal of goods and money and encourage him in his grandiose and extravagant schemes.

For depressive illness we have, in Electro-Convulsant Therapy, a ready, useful and comparatively reliable, safe and effective therapeutic measure. The majority of patients accept such treatment quite readily and respond well to it. Where there is a history of chronic or recurrent illness, leucotomy (often in one of its modified forms) seems to offer a good hope with an excellent prognosis. Depressed patients, moreover, from the very nature of their illness, tend to accept treatment, even if they dislike it, often maybe from poorly concealed masochistic urges and as punishment for what they believe to be their guilt and unworthiness.

Manic and hypomanic patients, on the other hand, present a totally different problem. Firstly they rarely, if ever, complain themselves and consequently they resent being referred to the doctor. When they do come it is often unwillingly or merely to demonstrate their well-being; or maybe to show some invention, gadget or discovery they believe they have made. Secondly, such patients, even when they have been seen, are notoriously unreliable over treatment and will rarely accept it. In the majority of patients it is only when under some form of control (which for all practical purposes means certification) that treatment can be carried out satisfactorily.

In Mania (and Hypomania) as in depression, convulsion therapy—usually E.C.T.—proves satisfactory in many instances, but the problem of long-term prognosis is not affected and in the case of recurrent manic attacks leucotomy seems to have no benefits to offer and is in fact often liable to make things worse. Any effective method of treatment is therefore to be welcomed, and more especially so if there is any suggestion that it can be continued after the patient leaves hospital, on a maintenance or prophylactic basis.