In discussing the late stage of head injuries, it is necessary first to define the clinical stages in the treatment of these conditions. With Donald Munroe, it is considered expedient to classify cases of head injury in general into— (a) Operative and (b) Non-operative cases.

Since the introduction of leucotomy by Lima and Moniz in 1936 numerous authors have reported their experiences with this form of treatment in mental disorders (Freeman and Watts, Fleming, Mayer-Gross, Hemphill et al.). Although leucotomy has stood the test of time well, and all workers agree that in selected cases its application is well justified, so that it has become an established form of treatment, there are many obscure clinical aspects which require elucidation. It is obvious that the collection of observations from as many angles as possible is necessary in order to further research in this promising field. It is hoped that a report on the results of leucotomies performed in this Hospital will be a contribution to that end.

You will, I am sure, share my regret that this lecture is being given out of turn. It had been arranged that my lecture should follow that of Prof. Mapother, whose untimely death robbed psychiatry of a notable figure and the Association of a lecture, possibly provocative and certainly stimulating, which promised to be a memorable addition to the series. I sadly miss, too, my old friend and colleague, Sir Hubert Bond, ever the kindliest and most charitable of critics.

It is well known that occupational therapy plays an essential part in the rehabilitation of psychoneurotic service patients. The usual occupations are carpentry, arts and crafts, gardening, and the like. At Mill Hill E.M.S. Neurosis Centre, marked success attended a supplementary scheme wherein selected patients underwent four-week courses at a nearby technical institute in mechanical and commercial subjects.

In this paper it is my intention to give a broad survey of vitamin B complex deficiencies and their influence upon neuropsychiatric abnormalities generally, whilst Dr. Hardwick will discuss in greater detail the syndromes more specifically associated with such deficiencies, amplifying his remarks by reference to cases we have treated in recent years.

Discussions on crime and punishment frequently bring into relief two fundamental facts: one that everyone is dependent upon his fellows; the other that the physico-chemical, biological and psychological or spiritual worlds are, as J. S. Haldane pointed out, only the same worlds at different planes of interpretation.

The social impact of mental illness, like that of other diseases which are covered by public health organizations, is governed by quantitative considerations. Two cases of typhoid fever are worse than one, and the same applies to schizophrenia. A principle, complementary to Bentham's doctrine of the greatest good for the greatest number, is the foundation of mental hygiene. The object is to try to reduce the total quantity of discomfort in the community due to mental illness. The effort is not expended only on people recognized to be ill enough to need hospital care. It includes those cases in the community who are less acutely ill and the members of the normal population, who have to tolerate the burden of mental illness in their relatives or associates. The basis of the whole activity is clearly quantitative. In order to comprehend the problem or to evaluate results of effort, adequate statistical data must be collected. It might be thought that to labour this point was unnecessary, and some may even consider it dangerous. Nothing is duller than the compilation of unnecessary statistics, official or unofficial, and nothing can be more misleading than numerical data collected or interpreted without proper forethought. I will therefore first draw attention to some erroneous conclusions, which have been sometimes drawn from statistical data in the psychiatric field.

In 1943 I published a paper on pellagra, in which I described in summary form twelve clinical cases from amongst patients with a psychosis of long standing at West Park Hospital. I also referred briefly to two other cases seen at the observation unit at St. Pancras Hospital, one of whom died shortly after admission, the other being subsequently discharged recovered from West Park. Since then I have encountered from time to time further cases, both amongst the West Park patients and those of recent admission to the observation unit. The diagnosis in each instance was clinical, being based on the well-known symptomatology of symmetrical dermatitis, glossitis (and often stomatitis), malnutrition and, as a rule, diarrhoea. The frequent association of malnutrition with mental disease led one to suspect that milder vitamin-deficient states, i.e. intermediate between frank pellagra and healthy nutrition, existed. I think that our clinical observations, together with subsequent research along biochemical lines, go to support this. If one adds to the foregoing the major and minor B1 deficiency states, one is forced to the conclusion that one is not dealing with academic rarities, but with a practical problem of interest to psychiatrist, physician and dietician. Moreover, recent research has yielded us powerful therapeutic weapons, such as nicotinic acid, aneurin and riboflavine, which, with certain reservations, have a specific curative effect in the corresponding deficiency conditions.

Protagonists of mental tests in clinical practice have hitherto shown a decided preference for methods of examination adapted to study capacities already developed or knowledge already acquired. Relatively little attention has been given to the study of learning, despite the fact that this function is so obviously affected in many and various neuropsychiatric conditions. One need only recall the widespread loss of plasticity so characteristic of the dementias and the more specific defects of learning associated with various types of focal lesion, e.g. of the language centres or the visual-association areas (cf. Cobb, 1944, pp. 214–5; Zangwill, 1945). It may therefore be urged that any technique of studying learning that is objective in character and easily adapted to the needs of routine clinical examination is worthy of attention. One technique which meets these demands will be described in the present paper, together with a small selection of the results obtained on routine psychological testing at the Brain Injuries Centre in Edinburgh.

Generalized xanthoma is a cholesterol disturbance of the cells, coincident with a normal lipoid content of the blood serum.

The case described involves the skull, dura mater, brain, pleura and gallbladder.

The discovery of the nervous impulse established that the nervous system was fundamentally mechanistic, and that it was highly dynamic; and all subsequent work has confirmed these earlier views. The stabilities of inanimate dynamic systems are frequently of high importance and rich in applications. It would seem likely that an investigation of the stabilities of the nervous system would yield interesting results, but it is only recently that the importance of stability in the nervous system has been unequivocally recognized. But it has now been established that such properties are of central importance in the processes of integration and co-ordination. Advance has probably been hampered by the difficulties of the subject.

This report concerns 100 patients treated by prefrontal leucotomy. The technique employed has followed that of Freeman and Watts.

In the case of the 47 manic-depressive patients treated the prognosis without operation was considered very poor. The majority (34/44) had failed to respond to electric convulsive therapy, which was contra-indicated in the remainder by reason of physical health. Seven out of these 47 cases had been in hospital under two years, but there was a history of many years' poor social adaptation or recurrent mental illness. The average duration of illness in the recovered cases of this manic-depressive group was 31 months. That of the failures 45 months.

It has been said that when a psychiatrist is appointed to a general hospital the staff only by stages come to make use of his services. The first phase is that in which he is called upon to dispose of those patients suffering from severe mental illnesses, whose behaviour is disturbing to the rest of the ward. In the next phase he may be called upon to deal with psychotics and severe psycho-neurotics. The third phase comes when surgeons and physicians refer to him all those patients they have investigated for whose symptoms no organic basis can be found. A fourth phase is when the psychiatrist is asked to co-operate in the treatment of such psychosomatic cases as asthma, colitis and migraine—and in the last phase, when the psychiatrist has proved his worth, he may be asked to advise on the handling of patients suffering from “wear and tear diseases,” frank organic diseases, such as gastric ulcer and hyperpiesia (1).

The problem of mental disease has been approached in many different ways, and chemical, anatomical, biological and psychological methods have been employed. In certain cases it has been possible to obtain satisfactory results by the use of one isolated method: the serological and anatomical approach has given us a useful solution to the problem of general paresis; the genetic approach has been equally useful in the study of mental deficiency. Such great results may explain the prevailing tendency in psychiatric research to attack all the problems of mental disease by the systematic use of one single method, in the hope that the final result is only a matter of time and of technical refinement. One author believes in the anatomical approach, another in the chemical; and there is a tendency to exclude other” methods, in the belief that they cannot give results of basic importance. Psychiatry also has its eclectics, but generally the most intensive research work is carried out by the various “schools,” and with a definite exclusiveness of methods.

The congeries of etiological theories and alleged cures that has accumulated round the subject of nocturnal enuresis in children proves only one thing—that we know little of the causes and treatment of enuresis. Since the war many cases of nocturnal enuresis persisting into adolescence and adult life have been seen. Presumably the sufferers were ashamed of their disability and concealed it in peacetime. But wartime conscription, often entailing absence from their homes, has compelled them to reveal it. Such cases of persistent enuresis represent the most severe form of the disorder, and an analysis of the factors involved would seem to be of more value than merely to study enuretic children in general. Once these facts are ascertained, they may throw some light on the universal problem of enuresis in children.

This investigation was carried out at Belsen between May 21 and June 27, 1945. As it was impossible to examine psychiatrically all the cases, only those showing evidence of psychological upset were referred for examination by the physicians. In addition, to obtain a cross-section of the population, I selected at random 60 to 70 cases in hospital and convalescent areas—ones that did not fall into the first group.

Military psychiatry is a large subject with widespread ramifications. The general scope of the work at home has been well reviewed in J. R. Rees's paper, “Three Years of Military Psychiatry in the United Kingdom”; I need not, therefore, try to describe what he has described so well. Even in the overseas field, I must unwillingly avoid the fascinations of detailed discussion of the aetiology and treatment of “battle neurosis” in forward troops; there is already a wealth of papers on this subject, including the valuable symposium at the Section of Psychiatry of the Royal Society of Medicine last November, in which Palmer, Kenton, Craigie and Main took part. Kenton's contribution, being based on work in North Africa and Italy, outlines some of the experience on which my remarks to-day are based.

Laughter, known to mankind as a physiological response to happy and comical events in general, is one of the most inviting guides through human life, but sometimes it may point to various morbid states of mind.

Physiological laughter has been studied by numerous psychologists and philosophers, the pathological part of the subject and compulsive laughter by many physicians, both clinicians and anatomists. Reading through the accessible part of the extensive literature on laughter one realizes that much has not yet been quite elucidated. In recent years we have had an opportunity of following a few most interesting cases of pathological laughter. This essay has been devoted to a review of the psychological, clinical and anatomical studies, and to an analysis of our five cases and their relation to epilepsy.