I. The Problem.

If we have a group of letters describing how discharged post-leucotomy patients are getting on, and what they are doing (1), it is useful to be able to determine how far the traits reported can be regarded as typical of post-leucotomy patients in general, peculiar to a particular clinical class, or unique to a single patient. Information of this kind clearly helps a doctor to predict what personality traits are likely to be noticed after the operation.

Knowledge of amnesia is dependent upon the subject's statement. He can tell us what he will. If he has studied the subject well, he can mislead us. He may have motives for fabricating. He may benefit, he thinks, financially, socially or in other material ways, by inventing an amnesia. A history of grave injury may produce avoidance of danger or of unpleasant work. A medical history, which the patient may think unusual, may give him prestige or sympathy. Finally, he may invent an amnesia to give the doctor a good story or to “pull his leg.”

In some of our earliest investigations into the effect of leucotomy we used the Rorschach test, hoping thereby to obtain a fairly full and clear-cut picture of the personality changes produced by the operation, but it was found that this test had the disadvantage that, when repeated, memory of the previous test or tests to some extent minimizes the validity of the later interpretations.

In this discussion of psychiatry outside mental hospitals, it is proposed to deal mainly with the field of psychiatry inside general hospitals. The idea of in-patient psychiatric beds in the general hospitals is certainly not new, and was tried out between the last two wars. One of the factors responsible for failure was a lack of effective therapeutics. Thus the comparatively small number of beds available were occupied for periods too long for ordinary general hospital practice, and facilities to ease long-term admission in occupational and social directions were usually lacking. The situation has not substantially changed from that described by Weir Mitchell, who caustically remarked that psychiatrists pleaded for opportunity to treat the early case, but when the plea was granted there was little that could be done. In the last few years advances in both psychological and physical methods have reached a point where certain categories at least of mental illness can be considerably helped by admission to a general hospital psychiatric unit, and be discharged in a period comparable to that usual in general medical wards. A report made in 1943 by the author at Sutton Emergency Hospital, and later, social studies by Brown and Carling, 1945, at the Radcliff Infirmary, Oxford, showed that the six weeks' average stay of the psychiatric in-patients was less than the average for medical patients of a general ward. It was not just a matter of performing a little diagnostic investigation and then transferring the patient elsewhere. In fact less than 8 per cent. of these psychiatric patients were sent to other hospitals. The full figures for a year's admissions are available in the 1943 report.

There are three particular pupillary movements in the course of the electrically-produced epileptic fit: dilatation during the convulsion, constriction in the post-convulsive stage, and spasmodic dilatation towards the final stages of the post-convulsive stage. The pupillary dilatation in the convulsive phase is identical with that found in the spontaneous epileptic fit, where it is generally considered as an expression of sympathetic activity, either the consequence of a general (Bumke, 1914) or of a focal cortical excitation (Foerster, 1936; Penfield and Erickson, 1941), or, an opinion held more recently, due to a hypothalamic mechanism (Delay, 1946).

Obsessional symptoms and depression often co-exist. There are obsessional neurotics who are subject to recurrent depressions, and there are patients with marked obsessional personality features, but not suffering from an obsessional neurosis, who develop severe obsessional symptoms in the course of their depressions only. I do not agree with those writers who maintain that the typical features of the obsessional character can be found in every case of manic-depressive illness.

Introduction.

This contribution is itself introductory to a larger subject, and is an attempt to present some physiological observations in a way that may stimulate the interest of psychologists and psychiatrists. Viewed from a biological standpoint, man is limited in his thinking and behaviour by his innate constitution, anatomically and physiologicallly. As a living, functioning individual he is much more than the mere sum of his parts, yet it is a fact that structurally he is made up of reflex arcs (receptor endorgans, afferent nerves, central nervous system, efferent nerves and effector organs). The vital functions of nutrition, respiration, circulation, excretion, reproduction, locomotion and metabolism are effected by standard types of reflexes which pervade the vertebrate kind, so that a dynamic reflexological approach to normal and abnormal human behaviour should be revealing. Man is stimulated by his total environment to respond as a complete being, and this full activity is retained as experience which modifies subsequent behaviour. That being so, the nature of integration of these reflexes and the ways in which they are influenced by experience constitute a subject very pertinent to the study of psychology and psychiatry. Something of that nature forms the material of this paper.

This paper attempts to describe in detail the results of an educational programme aiming at the improvement of reading (accuracy, comprehension and speed) in a class of high grade educationally subnormal boys who were all in one or the other respect unsuccessful readers. For the purpose of this paper an unsuccessful reader is defined as a reader whose power of word recognition, of fluency of reading or of understanding is below the level expected from him. It has been assumed that this level is indicated by the mental age, though it has been kept in mind that the result of a verbal intelligence test need not be the final decision as to the intellectual capacity of a child.

From the available literature it appears that inhalational abscess of the lung following E.C.T. is a rare condition, but it is difficult to assess the actual incidence. Cook (1944), in his extensive review of the subject, quotes Meduna and Friedmann (1939) as stating that lung abscess occurred in 0.1 per cent. of cases, but this probably refers to patients undergoing metrazol convulsions, in whom there is an additional risk of embolic abscesses due to mobilization of thrombus at the site of injection. Jessner and Ryan (1943) mention that aspiration pneumonia may complicate metrazol treatment, and that pulmonary abscess may occur as a result of old pelvic thrombo-phlebitis or from mobilization of thrombus at the site of injection. They do not refer to inhalational lung abscess complicating E.C.T. Sargant and Slater (1944) state that chest complications are rare after convulsion treatment. Kraines (1943) and Brain and Strauss (1945) do not discuss the condition. Vassallo (1946) in an unpublished series of over 300 cases has observed one inhalational lung abscess. Kalinowsky and Hoch (1946) say: “The development of pulmonary diseases during treatment is rare in E.C.T., but was quite frequent in metrazol therapy.” They mention some possible reasons for this, e.g. abscess due to mobilization of thrombi at the site of injection. They add: “The literature on E.C.T. contains only one case of pulmonary abscess” (Kalinowsky and Werthing, 1943). The paper quoted, however, merely states, that the patient developed a lung abscess which was successfully treated with sulphanilamide. All authorities agree that pre-existing lung disease, and especially tuberculosis, is a strong contra-indication for E.C.T. Since there are so few references to this illness in the literature it seems profitable to describe a case.

The general importance of studying the mental health of British troops in the Far East is obvious enough. It is perhaps less obvious that this importance is unlikely to have diminished with the end of the war; for there are still many troops serving in the Far East, and presumably will be for some time.

It is generally recognized that the capacity to grasp new ideas and learn new methods of work depends partly upon a person's intelligence and partly upon his age. It is also recognized that over-taxing a person's capacity to acquire new methods of work, or inadequate opportunities for a person to develop the capacity he possesses, are sources of dissatisfaction, mental strain, and sometimes physical complaints amongst normally healthy people. There is even reason to believe that amongst less healthy people they contribute towards disaffection and illness.

I wish to make it clear at once that for the purpose of this paper I am taking the definition of psychiatry as being synonymous with the term psychological medicine—in other words, the study of the subject as a whole.

The results of leucotomy in mental hospital practice are already well known and are familiar from the Board of Control's review of 1,000 cases published in 1947.

I am not aware that in mental deficiency institutions the operation has become a practice in application to cases presenting gross abnormality of conduct having its origin in mental disorder which, though not amounting to one of the insanities, has the characteristics of a psychopathic state.

At the beginning of the war part of the Maudsley Hospital moved to Mill Hill School, and a neurosis centre of 550 beds was established. During the six years of war some 20,000 neurotic patients, both forces and civilian, were treated at this centre. Within the centre a special unit for the study of Forces patients with effort syndrome (E.S.) was set up. This unit was in existence from 1939 to 1945, and during this period 2,324 cases of E.S. were treated. The writer was associated with this unit throughout, working in association with a cardiologist (Paul Wood (1)), and with other psychiatrists (Lewis (2), Guttmann (3), Gillespie (4)). Much of the material brought together in this thesis has already been published (Jones (3, 5, 6, 7, 8, 9, 10, 11, 12, 38, 43)). During most of the war years the writer was in receipt of a Medical Research Council grant.

Since the introduction of prefrontal leucotomy by Moniz in 1936, an ever-increasing number of psychotics have been subjected to this operation. Results have been very satisfactory in certain types of psychosis and psychoneurosis, especially in obsessional tension states, in agitated depression, and in patients with considerable apprehension and anxiety, while less favourable results have been reported in many cases of schizophrenia, hebephrenia, and others. Naturally, with the number of cases operated on, experience has grown, and psychiatrists, neurologists as well as psychologists are nowadays, to some extent, in a position to determine which case is likely to benefit from the operation, and where leucotomy should rather not be resorted to.

Though twelve years have now passed since the first prefrontal leucotomy was performed, the status of this form of therapy is still far from settled. There are some who would never perform the operation at all; and some who would reserve it for the chronic sick; while others (Fleming, 1944) would advise its use at an early stage in the illness in cases where there were reasonable grounds for believing that recovery would not otherwise occur. With opposition of a purely emotional kind, the profession as a whole need hardly concern itself; for appeals that the integrity of the nervous system be maintained at all costs are unlikely to impress those whose daily work brings them into contact with the personality degradation of chronic mental illness. It is difficult to see why interference with the brain in order to save sight or to save life in the case of tumour should be regarded as either more or less wicked than interference designed to save human reason.