A search was made for statistical studies of the remission rate in cases of schizophrenia which had received no specialized treatment such as hypo-glycæmia. The search was confined to the period since 1918, as the period influenced by broader and more hopeful views of the nature and prognosis of “dementia præcox”. It was also confined to studies in which the remitted cases had been followed up for some time after discharge to avoid errors due to early relapses. The results of all these statistical follow-upstudies aie given in Table I. The various writers have classed their results in somewhat different ways, and it has been necessary, in constructing the Table, to fit all the results under standard headings.

The title of this paper may seem over-ambitious in the scope which it predicts, for it is obvious that much more space would be required to cover all the ground. It should be made clear that we are concerned here mainly with the administrative side of child guidance, which has of late years become a vital concern to the members of this Association. During the past few years there has been growing in the minds of all those interested in the promotion and preservation of mental health a belief that a co-ordination of existing mental health services should be carried out. At present these services are too sporadic and are uneven both in distribution and efficiency. London and the great cities are rich in mental health services of all kinds, but in the counties and smaller towns there are but meagre provisions. This is well illustrated by the voluntary societies concerned with the treatment and prevention of mental illness. There is, for example, the Home and School Council, which works on the principle that a better relation between parents and teachers constitutes a creative force in mental health, and further provides a unique channel through which mental health knowledge can be brought before the general public without the risks attached to indiscriminate propaganda. Another society, at the other end of the scale, is the Mental After-Care Association, which attempts to bridge the difficult gap which patients experience between leaving a mental hospital and taking up life in the ordinary world again. Yet another society is the National Council of Mental Hygiene, whose broad aims are to educate the public in mental health matters, to promote closer association between psychiatry and general medicine, to further the early treatment of mental disorders, etc. The Central Association for Mental Welfare was, at its inception, mainly interested in the problems of mental defect, but now has a wide range of activities, such as the organization of training courses for medical officers, teachers and mental welfare workers, co-ordinating local activities in many areas and making provision for cases which fall outside the scope of smaller authorities, and undertaking public activities relating to propaganda and the promotion of legislation. In a more limited field the Child Guidance Council attempts to encourage the provision of skilled treatment for children showing behaviour disturbances or early symptoms of nervous and mental disorder and, in general, to further the practice of child guidance. In addition to those societies which are directly concerned with mental health, there are many others, such as the British Social Hygiene Council, the National Association of Probation Officers, the R.S.P.C.A., the Howard League, the National Institute of Industrial Psychology, whose work lie on the borders of this field. It is obvious that there is a great deal of overlapping, and the need for co-ordination is being attained through a temporary reconstruction committee under the chairmanship of Lord Feversham, which will shortly publish a report.

Although considerable attention has been devoted during the past years to the problems of the influence of heredity on mental deficiency, no final conclusions have yet been reached. It appears well established at the present time, first, that in a large percentage of cases, variously estimated at from 40 to 80%, mental deficiency is significantly determined by genetic mechanisms, and second, that recessive genes seem to play a considerable role in such mechanisms (Lokay, 1929; Brugger, 1930a; Smith, 1930; Luxemburg, 1931; Juda, 1934; Kreyenberg, 1935).

In spite of Freud's great discoveries tracing back the origins of adult psycho-neurosis to the mental conflicts of early childhood, until comparatively recently little was done by psychiatrists generally to investigate and treat directly the mental problems of difficult and neurotic children. Though a few clinics had been established for a considerable time in Vienna and elsewhere as a result of the work of Adler and his pupils, the “Child Guidance “movement obtained its greatest impetus from America. Here it arose, however, out of social problems rather than medical; more particularly from Healey's studies of delinquent children. Partly on account of its origin in this way, and partly no doubt influenced by the behaviourist psychology so much in evidence in U.S.A., the tendency there from the beginning was to stress the importance of the child's environment and the remedial effect of altering harmful influences found in it. The psycho-analytic schools, on the other hand, have emphasized the endogenous nature of neurotic conflict, i.e., localized the trouble wholly in the child's mind; which has led them to concentrate on treatment of the child itself to the exclusion of the material surroundings.

It is not known to what extent convulsions induced experimentally by various agencies are related pathogenetically to epileptic fits. There are, however, facts which suggest that the induced convulsions have, in their several mechanisms, points in common with one another and with epilepsy. Thus, caffeine and absinthe both cause convulsions in cats; when sub-convulsant doses of both are administered together convulsion ensues, suggesting that the two drugs operate on the same mechanism (Notkin and Pike, 1931). Insulin hypoglycæmia occasionally causes convulsions; it has been shown that during hypoglycæmia in man there is a lower fit-threshold to cardiazol (Georgi and Strauss, 1938), and in cats to thujone (Keith, 1935). The elicitation of convulsions by electrical stimulation of the cortex is facilitated by camphor monobromide, absinthe (Muskens, 1928), and cardiazol (Santha, 1939) on the one hand, and in epileptics as opposed to non-epileptics, on the other (Pen-field, 1936). Hydration has been shown to play a part in the precipitation of convulsions due to hypoglycæmia (Drabkin and Ravdin, 1937), thujone (Keith, 1935), and epilepsy (Fay, 1929; MacQuarrie, 1929).

In the extensive literature on sleep therapy some fifty complications have been recorded by the various authors. In a previous article (Journ. Ment. Sci., November, 1937) these were listed (pp. 660, 661) and divided into four main groups as follows:

1. 1. Common complications: Representing mainly normal by-products of the treatment.

2. 2. Complications involving particular tissues: Representing tissue idiosyncrasy.

3. 3. Accidents.

4. 4. True toxic complications: Representing a group which could not be regarded as either a necessary by-product of the treatment, an unavoidable expression of disproportionate sensitivity on the part of a particular tissue, or an accident which might be avoided.

The concept of accident-proneness is by no means a new one; but the term has passed into popular use, and although the colloquial usage of the term is frequently incorrect, yet the idea that some people are more liable to sustain accidents than their more fortunate fellows is now widely accepted. Of late years psychologists have made it their business to inquire into the nature of this susceptibility to accidents, and have found that whilst mankind in general is characterized by this proneness, there are individual differences in the degree to which it is possessed. In any sufficiently large observational group it is usually found that most of the accidents are sustained by a minority of the members of that group, and it is obviously of importance to discover what are the personal qualities or lack of abilities which make this minority specially accident-prone.

Nicole and Fitzgerald's assumption in 1932 that the Wassermann test had at last passed to rest in the limbo of historically interesting experiments can hardly be said to be correct, and the test still remains to-day as the standard method for the sero-diagnosis of syphilis. At the same time the steadily increasing specificity of flocculation tests and their value as ancillary procedures cannot be denied, and the accepted diagnostic ideal is a parallel examination by one of these and by the Wassermann test.

During the last twenty-five years it has come to be recognized that a fairly large amount of mental deficiency appears to coincide with or result from faulty intracranial myelination. In some such children little or no post-natal development occurs, in others recession is already occurring at birth; a few remain fairly normal for some years. Spastic contractures, especially of the legs, grow progressively worse, epilepsy may appear, the child goes steadily downhill and early death is the usual termination. In some cases choreoathetosis is present, and this may either, if the patient lives long enough, disappear spontaneously, or, more usually, become impossible when the spastic contractures have immobilized the extremities. Post-mortem one finds one of two conditions—demyelination of the brain (the status dysmyelinatus of Hallervorden-Spatz) or hypermyelination (the status marmoratus of the Vogts). In both forms there is much hypergliosis, evidently secondary to some irritating but slow myelin poison which finally produces anoxia. Clinically during life both varieties appear much the same, and that is all that is known about its nature at present. Cases were recorded by the Vogts in 1920, Hallervorden and Spatz in 1922, Kalinowski in 1927, Helfand in 1931, Spatz and Peters in 1938; in this country by Meyer and Cook in 1936, Meyer and Earl in 1936. By these authors the views of others are summarized—Bielschowski, Loewenberg and Malamud, Urechia and Michalescu, Bouché and Van Bogaert, Casper, Ammosow, Bostroem, Bodechtel and Guttmann. If epilepsy has been present, it generally disappears after some years. By no means all cases end up as helpless idiots; some learn to attend to their own wants, but few ever walk freely.

On the subject of the correlation of neurological lesions with psycho-pathological phenomena, two eminent neuro-histologists, the Werthams, have recently written: “It must be pointed out that in proportion to the extraordinary complexity and differentiation of the finer functions mediated by the central nervous system, histological lesions are very gross. However we may conceive of the functional processes going on in the central nervous system—physiological, physico-chemical, metabolic, electrical, etc.—it should be obvious that only the grossest miscarriages and defects would become morphologically visible. Structural lesions are the effect of functional reactions that are not histologically demonstrable. Physico-chemical changes, metabolic processes, functional changes of blood-vessels, and similar biological phenomena that cannot be micro-histologically demonstrated, precede the anatomically visible lesions which occur only where the processes have attained a certain intensity. What we can demonstrate histologically in the nervous parenchyma is not by any means an adequate basis for the understanding of the quality, intensity or normality of nervous functions. In a patient who dies in the convulsions of tetanus, the anterior horn-cells may reveal nothing abnormal. Even the most minute and complete histological examination of the central nervous system in a case may fail to reveal any evidence of an existing profound disorder of brain function. There are cases of idiocy of the severest type in which no significant histological changes may be demonstrable in the brain.”

The stimulus behind this investigation was created by various factors which can only be enumerated briefly. In the course of routine sero-diagnosis of syphilis in psychiatric work at the Institute during the last five years, it became evident that, of the three flocculation tests employed, the Kahn (Kahn, R. L., 1928), Müller-Ballungs reaction (Müller, R., 1929), and Meinicke Klarungs reaction (Meinicke, E., 1929), the Meinicke original extract gave results superior in sensitivity. This feature was shown particularly in very early infections and treated cases. Three Wassermann tests, the standard method for psychiatry (Mann, S. A., and Partner, F., 1931), the Wyler drop technique (Wyler, E. J., 1929), and the Browning and Kennaway methods (Browning, C. H., and Kennaway, 1924), run concurrently, could not claim to be as good in this respect, and further, were liable to give non-specific results. The explanation of some of the anomalous reactions of one or another of the three hæmolytic systems seems to lie chiefly in the fact that sera from psychotic and mentally defective patients contain in larger degree elements that are prone to disturb specificity.

The electro-encephalogram (E.E.G.) is a record of the electrical potential changes of the brain as recorded by placing electrodes on the scalp without opening the skull. The technique is similar to that used in obtaining a electro-cardiogram, and in the apparatus shown three independent recorders are used, for reasons to be described later.

This method appears first to have been used in the U.S.A. by Kunde, Hall and Gerty (1927) and then by Mackenzie (1927) in this country. Later Driver and Shaw (1933) gave divided doses of typhoid vaccine, and Schnitker (1934) gave typhoid H antigen. T.A.B. vaccine, containing one thousand million dead B. typhosus and seven hundred and fifty million each dead B. paratyphosus A and B per c.c., has been used here since July 6, 1928.

Attempts to find a function characteristic of schizophrenia which may be correlated with the electro-encephalogram have not been very fruitful. For example, in a group of 60 adult schizophrenics only a very slight positive correlation exists between the electrical activity of the brain and duration of illness (Rubin, unpublished observations). The same correlation obtains for duration of hospitalization. Although not systematically studied, there appears to be no correlation between the electro-encephalogram and diagnostic sub-type of schizophrenia.

Since sulphanilamide has been shown to be of value in the treatment of infections due to a variety of organisms, it was thought that it might be efficacious against bacillary dysentery.

In any search for enteric carriers the patient with a positive blood-agglutination must be regarded as suspect. Earlier workers were of opinion that the converse of this was true—that a negative agglutination reaction implied that the case was not a carrier. It is true that McCowan and Mann (1925) described a series of nine carriers, of whom two showed a negative agglutination reaction during the clinical attack of typhoid fever, but the subsequent history of the agglutination reactions is not given. Ashby (1931) indicates in his series the prevailing belief that carriers show significant alterations in their agglutination reactions. Although repeatedly controverted in the medical literature by the publication of small groups of cases where the carrier state has been accompanied by negative blood-agglutination reactions, this view dies hard, and was revived during the recent discussions centring around the Croydon typhoid epidemic.

In round figures there are 11,000 epileptics in public mental hospitals, 3,000-4,000 in institutions for mental defectives, just under 4,000, who are neither insane nor mentally defective, in colonies and residential schools, and an unknown number, probably a considerable one, in public assistance hospitals and institutions. How many are living in the community is not known.