Mr. Caradoc Jones this morning emphasized very clearly indeed the important distinction between high and low grade mental deficiency. He showed us some very striking figures suggesting, not that heredity is not involved in both, but that it is a different sort of heredity. It always seems to me that in considering this and related matters the analogy of stature is a helpful one. Many of us remember those posters of the last war but one, which said “Your King and Country Need YOU,” coupled with the statement that “You” had to be 5 ft. 4 in. high—a standard which went down afterwards. If one rejects for any purpose a segment of the population on a measurement of this kind one is rejecting people for very different reasons. The arbitrary standard cuts off, of course, the dwarfs; the achondroplasics, the midgets, the cretins, the rachitic dwarfs, and so on; but it cuts off far more of those who are simply short. In causation we can normally expect the dwarf's condition to be due to hereditary factors, actually a single factor in achondroplasia; or it may be something environmental, as in the rachitic dwarfs or the cretins, but when we come to the people who are just short, it has been shown fairly conclusively that in a civilized community in which the standard of nutrition is adequate, at least 90 per cent. of the differences are due to heredity; but it is a different sort of heredity. We have a whole host of genetic factors, each one of which has a small effect; but the effect is cumulative; some factors make for greater stature, some for smaller, and it is on the sum total received from the parents that the stature of the individual depends.

This child developed signs of a serious mental illness during an attack of jaundice three years ago, just before his 11th birthday, and the condition has continued to develop up to the present time, though not quite evenly. At one period the illness was thought to have remitted, but it is evident in retrospect that the remission was, in fact, characterized by regression in behaviour and considerable invalidism. The clinical picture showed sustained mutism and one postural oddity as the most prominent features; and in other respects the child showed an interest in his environment and participation in outside activities which in an adult with a similar diagnosis would be regarded as unusual. There was a morbid heredity in the case and a personality of distinctly pathological character which was clearly shown by his behaviour during his early years. The genesis of the reaction was complicated by an acute infective illness and by two head injuries, neither of which now appears to have been of importance, but which led to much clinical obscurity at the time. The anomalous clinical pattern and the inability of the child to communicate his experiences illustrate the difficulties of diagnosis at this age, and an attempt is made here to outline other possibilities which need consideration and the reasons in this case for rejecting them.

Writer's cramp, crampe des écrivains, scrivener's palsy, graphospasm or mogigraphia may be defined as a condition of inco-ordination of the small muscles of the hand which appears only when attempting to write. The various names given to this condition emphasize that cramp or spasm is the predominant feature, and Osler thought that it was an early symptom. As the principal nerves and muscles are often intact and movements of a wider range can be carried out efficiently, the condition appears to be a functional disturbance of co-ordination.

Exhibitionism was stated by East to be the commonest sexual offence for which men are received into prison; this proved to be true in 1946, when 98 men charged with exposing themselves were received into Brixton Prison during the year. Exhibitionism is customarily dealt with under Section 4 of the Vagrancy Act, 1824, and the offender is charged with being a Rogue and Vagabond in that he “did wilfully, openly, lewdly and obscenely expose his person with intent to insult a female.” The term “exposure of the person” is presumed to be synonymous with exhibition of the genitals. The 98 cases about to be discussed represented 32.2 per cent. of the sexual offences and 1.95 per cent. of all offences received into the prison during 1946. Exhibitionism presents a difficult problem both to the doctor and to the layman, as it is often apparently nonsensical and meaningless. All cases received into prison are specially interviewed as a routine and frequently the Court requests a report as to the accused's state of mind. In this series this was requested in 88 cases—a much higher proportion than for any other offence.

The association of obsessive compulsive states with organic disease is well known and a prolific and abundant literature dealing with it has accumulated in the last twenty years. The combination of obsessive compulsive states with epilepsy, however, has received very little attention and in some of the cases in which it has been reported it has been regarded as a coincidence. This may very well be so, but the case here described is of interest in showing the combination very clearly, and it would not perhaps be very odd if there were a small group of epileptics with obsessive compulsive states, in whom both manifestations were ascribable to a common pathology.

The intelligence of epileptics has been studied by many investigators. Some of these studies were confined to children, some to patients in institutions, others to out-patients and a few to private patients. Some studies included institutionalized and non-institutionalized patients with no effort made to consider the two groups separately. The out-patient material was assumed to represent the best cross section of epileptics, but as Somerfeld-Ziskind and Ziskind (1) point out, patients who are not helped by the treatment tend to stop attending clinics. This bias in the material is reflected in the wide variations of the results; for example there is a range in the reported mean I.Qs. of from 113.5 to 78. There appeared to be a definite need for a study based on a wider group, representing all types of epileptics. Examination of whole sections of the population, carried out during the recent war, afford a unique opportunity for this study, for the group was absolute, and there were no selective factors except sex, age and institutionalization.

Gunshot and shrapnel wounds of the head during the war have produced various disabilities not commonly seen in the injuries of peace-time.

The symptom complex which usually appears subsequent to head trauma has become very familiar during the past few years. The resemblance from case to case of certain sequelae to head injuries has been grouped together in syndromes, variously labelled post-concussive syndrome, post-traumatic personality change, post-traumatic neurosis and post-contusional state, all indicating an oft-recurring persistent disability following concussion of the brain.

Modern treatment of epilepsy is directed towards (1) the control of the fits, and (2) the diminution or abolition of the underlying cerebral dysrhythmia.

In this paper I shall give my personal observations on 196 patients treated with epanutin in the Maghull Colony over a period of 6 years.

Commenting on the different symptoms produced by disturbances of the left hemisphere (aphasia, apraxia, etc.) and of the right (dreamy states, hallucinations, etc.), Hughlings Jackson on many occasions pointed out that there exists a “duality” of the brain; the anterior parts of the left hemisphere serving more controlled and objective purposes, the posterior parts of the right more subjective† and the anterior parts of the right serving more automatic purposes. Consequently, quoting Bastian and Rosenthal to support him, he tendered the suggestion that “mental” symptoms might be indicative of a disturbance particularly of the posterior parts of the right hemisphere (in right-handed people).

It would seem that the overwhelming success of convulsion therapy in depressive syndromes has retarded recognition of the use of this treatment in states of excitement. Little has been written in this country on E.C.T. in mania, and apart from a report that the condition is refractory and frequently relapses, there is scant guidance on the subject. The object of this paper is to draw attention to the real value of E.C.T. in mania, when given in adequate quantity at the beginning, and followed up by frequent spacing of shocks to prevent relapse. For this purpose, “intensive therapy” is regarded as that which commences with several shocks daily until the excited state is suppressed, and by this method the most maniacal patient can be rapidly and dramatically brought under control.

At a time when treatment by electrically induced convulsions is attaining a rapid and widespread popularity in clinical psychiatry, it is well to take stock of alternative methods. The purpose of this paper is to describe a method of modifying the treatment of mental disorders by leptazol (cardiazol, metrazol, phrenazol) so as to remove the unpleasantness hitherto associated with this treatment. Though leptazol therapy is still widely employed in psychiatry, its use has, for two reasons, become increasingly restricted. Firstly, it is very unpleasant for the patient; secondly, newer physical treatments, no less empirical, often yield better results in the conditions in which it was used.

Now that more than six years have elapsed since the introduction of leucotomy in this country, it is becoming possible to assess more accurately its remoter effects. The increasing use that is being made of the operation bears witness to the beneficial results that have been obtained by it, but the justifiable enthusiasm occasioned by the dramatic improvements it has produced in some cases apparently resistant to all other present-day methods of treatment must be tempered by a sober consideration of all the sequelae of section of the prefrontal fibres. While it is undoubted that after it many cases are sufficiently recovered to resume a full and satisfactory social life, and an even larger number are either freed from intense misery or from hostility and aggressive impulses and enabled to take a more co-operative part in the sheltered life of a hospital community, there are a few whose behaviour following the operation is definitely less satisfactory than it was even at the height of their illness. Furthermore, even in the successful cases, certain undesirable traits have often been noted.

The characteristic trait of the doctor's medical activity, compared with the quack's, is that the doctor is guided by two theoretical and practical postulates. The first one is diagnostic, and implies that the doctor must try to state the nature of the disease. If this is not possible, he must at least make an analysis of the symptoms in order to establish their patho-physiological connection, so that he knows which are the most important and most susceptible to treatment.

In June, 1940, the first Area Psychiatrists in the United Kingdom, of whom I was one, were appointed. Although at first we were told that there were not many psychiatric cases, and in spite of the lack of encouragement in some areas, clinics were set up, and very soon the psychiatrists were overwhelmed by the number of patients sent, both officers and men. It became apparent to all of us who were doing the work that many of the men could have been eliminated at the source, for by going into the history of the individual patient, and giving him intelligence tests, one could have foretold fairly accurately his future in the army, i.e. whether he would be able to be trained as a soldier in a particular arm, and his length of service before his breakdown. But the process was that of elimination. The psychiatrist working alone managed to sort out the soldier, but there was at that time no disposal method except to hospital, which was not very useful for the dull and backward, and the chronic anxiety states. At the end of 1940, at the suggestion of a Command Psychiatrist, a Directorate of Officer Selection Personnel was set up, so that men joining the army would have their intelligence tested, and be interviewed by a personnel selection officer, and the dull and backward and the difficult cases interviewed by the psychiatrist, either for rejection from the army or for transfer to the unarmed or armed Pioneer Corps, or to any arm which was considered suitable. This process has continued since then, and has made great strides. At present no man is posted to any particular arm, but he comes into the army to primary training centres, where he is tested and interviewed, and after six weeks' general training is then posted to the arm most suitable for him. This procedure helped the problem of “other ranks,” and it was hoped that the incidence of psychological illnesses in the army would be lowered, and the number of men sent to the psychiatrist brought within reasonable limits. Till then, the psychiatrist in the army had been working very fast, seeing as many as thirty to one hundred men a day.

This study of retrograde amnesia of brief duration is based upon information furnished by 117 persons who had undergone, according to their statements, one or more terrifying incidents. All were men on full military duty, with the exception of three civilians, included as being of particular interest. In many investigations the information has been obtained from patients in whom motives other than accuracy could have taken a part in their descriptions. A patient may invent, distort or exaggerate his amnesia for psychological, or material and pecuniary, aggrandisement. In this series 99 of the cases were voluntary applicants for officer-training.