Mr. President, Ladies and Gentlemen: as my contribution to this morning's topic, “Legislation and Mental Health,” I had hoped to be able to give you the outlines of the proposals contained in a new Mental Health Bill under way in Northern Ireland. Time has not been on my side, as it just happens the Bill is being presented to-day for its first reading in the Northern Ireland Parliament, and as only after that will it be available for publication, I am not able to make use of it as the basis of my paper this morning.

I cannot tell whether it is purely a matter of chance that in Uppsala, a university town, I have had to treat difficulties at school in children of average or superior intelligence to a greater extent than in Stockholm where I practised earlier. It is obvious that everywhere the most usual cause of such difficulties is either subnormal intelligence or special difficulties in reading and writing, that can be classed among the aphasic disturbances, most commonly in the form of dyslexia. In Uppsala, however, I have encountered a relatively large number of cases with difficulties of other kinds that are not described, or only mentioned, in current textbooks on child psychiatry.

Treatment by prefrontal leucotomy, though undoubtedly of value, still rests upon an insufficiently scientific basis. Its anatomical and physiological effects are being increasingly discovered, but many of its psychological effects are still unpredictable and obscure. Its effect on intelligence, on immediate memory, and on simple learning ability are now well known, but with these we are not concerned. Rather, we have attempted to assess the effect of leucotomy on “creative ability.” By this phrase we shall refer to that ability by which the ideational content of past experience is utilized in a situation to provide concepts and actions not directly evoked by the new situation, but elaborated by the patient's more complex cerebral reactions to the situation; The ability is worthy of examination, since the more intellectual the work the more is it evident. The architect, for instance, needs more creative ability than the bricklayer, the novelist more than the amanuensis, and the Royal Academician more than the house painter.

The generalized foetal dysplasia known as mongolism is one of the most frequent causes of severe mental defect. It accounts for something like 5 per cent. of all institutional cases in this country (Tredgold, 1929). The incidence of the condition in the general population is difficult to estimate with accuracy because of the high mortality it carries, but an exact knowledge of the frequency would be useful both for biological and for administrative reasons.

Thiamine or aneurine has for many years been known as the anti-neuritic vitamin, although action of this substance in organic nervous trouble is not established. Less well-known is its action on the higher cerebral processes, but results of investigations appear to show that it has a definite effect on these. M. V. Dias (1947) found that the application of thiamine hydrochloride solution to the motor cortex of unanaesthetized dogs produced clonic contractions of the appropriate muscles, and Harrell (1946) reports striking psychological results on normal children.

Tashiro (1922) showed that the isolated frog nerve liberates ammonia on stimulation, and Richter and Dawson (1948) have recently found that ammonia is liberated on stimulation by the brain. Ammonia is very toxic to the brain, on which it has an irritant action; but the brain may be protected to some extent by the enzyme system described by Krebs (1935), which can detoxicate ammonia by combination with glutamic acid to form glutamine. Sapirstein (1943) obtained evidence that this system is active in vivo by showing that glutamic acid increases the resistance of animals to convulsions produced by injecting ammonium chloride. The toxic action of ammonia on the brain is also of interest in connection with the view that it may be concerned in certain forms of epilepsy (Harris, 1945). This view is supported by the observations of Price, Waelsch and Putnam (1943) on the inhibitory action of glutamic acid on petit mal attacks.

The treatment of depression with desoxyephedrine (pervitin or methedrine) is not new. In 1943 Davidoff reported a comparison of the effect of this preparation with amphetamine and dextroamphetamine on 8 normal and 8 depressed individuals. He found that desoxyephedrine gave the most rapid results, acted the longest and produced the greatest motor activity the most often.

Turpin and Bernyer (1947), working on the influence of heredity on the Arneth count (Cooke and Ponder's (1927) modification), found that in mongols it was shifted to the left, i.e., that their polymorphonuclears had fewer lobes and were therefore more immature.

The 68 patients surveyed in this paper form a companion group to the equal number who have been discharged from hospital and of whom a follow-up study has been published by Frankl and Mayer-Gross (1947). The patients' condition was studied during the early months of 1947, when they had remained in hospital from 1 to 4 years after operation or had returned after an unsuccessful attempt at discharge. To what extent they have to be considered as failures will be seen in the paper. They are of special interest not only as a contrast to the more successfully treated patients, but also because a closer observation of the course of their illness was possible than with the discharged group. Being under constant clinical observation since the operation, all significant changes in their condition have been recorded and the important problem of relapse, neglected in the large literature on leucotomy, can be discussed on the basis of these observations. Finally, an answer was sought to the question of why these patients should have reacted less favourably to the operation than their fellows.

The adrenal cortex is the pivot of the body's reaction to stress. To this gland converge most of the varied effects of shock and stress, and from this gland diverge the steroids which, in ways but partly known, enable the body to withstand the stress. No apology is therefore needed for a study which contributes to an elucidation of the actions of these steroids.

Many writers on the subject of the treatment of addictions have suggested that for treatment to be efficacious, a period of detention legally enforced is necessary, and it is perhaps strange that a country which tends to regard personal failings and idiosyncrasies with a kindly eye has been probably the first to provide a method of enforcing it without recourse to a legal sentence.

Electronarcosis is the term applied to a sleep-like condition produced by the passage of an electric current through the central nervous system.

The loss of consciousness in hypoglycaemia is generally regarded as a direct consequence of the fact that the brain cells are being increasingly deprived of glucose, their principal fuel. The prompt relief of symptoms by glucose administration led to a number of investigations on the effect of other substrates known to sustain the respiration of surviving brain slices in vitro. Amongst these are various mono- and disaccharides, and such acids as lactic, pyruvic, succinic or glutamic acid which may be formed from glucose in the course of its metabolism. It appeared, however, that, in contrast to their in vitro action, most of these substances, including glutamic acid, were unable to relieve the symptoms of hypoglycaemia in eviscerated or hepatectomized animals (Bollmann and Mann, 1931; Maddock, Hawkins and Holmes, 1939). Similarly, lactic and pyruvic acids were found to have no effect on the oxygen consumption of the brain or the comatose state of hypoglycaemic patients undergoing insulin shock therapy (Wortis and Goldfarb, 1940; Goldfarb and Wort is, 1941). It has been shown for several substrates, including glutamic acid, that their rate of diffusion from the blood stream into brain tissue was markedly slower than that of glucose, and that therefore the concentration necessary for the maintenance of nervous function was not reached (Klein, Hurwitz and Olsen, 1946; Klein and Olsen, 1947). In harmony with this are the observations of Fried berg and Greenberg (1947), and of Waelsch, Schwerin and Bessman (1949) that intravenously injected glutamic acid is not taken up by brain tissue. The differences between the in vitro and in vivo results seemed to be adequately explained by these experiments.

Considerable material is available about the effect of leucotomy on intelligence. There are, however, few reports of objective measures of changes after leucotomy in the non-intellectual aspect of personality, those changes of temperament and character which are so striking to the clinician. In order to make a small contribution to filling this gap, at the suggestion of Dr. Desmond Curran an investigation has been carried out at St. George's Hospital and its In-Patient Unit at the Atkinson Morley Hospital, London.

The assessment of a patient's bodily habitus has now become an important part of clinical investigation in many medical fields.

Mr. Cecil Gray, in his excellent study, Peter Warlock holds the view that Philip Heseltine's character only becomes understandable if he is regarded as an example of dual personality. Gray gives very clearly and, in my opinion, conclusively the evidence on which he bases this belief. The only question that is left unanswered is the clinical nature of the duality.

Re-testing of the same individuals is a measure of the reliability of a test, a high correlation indicating that the results are consistent. Wechsler found the correlation for his test was ·94±·013 for 32 children aged 10–13 years re-tested from one month to one year later, and ·94±·018 for 20 adults aged 20–34 years re-tested after the same intervals of time. These figures indicate that the test itself is reliable.

The finger-prints of mental defectives have been investigated by Bonnevie (1927), Poll (1935) and M⊘ller (1935). It was found that the frequency of whorls was less in the feeble-minded and imbeciles than in the general population but there was no correlation between intelligence quotients and quantitative values of patterns among defectives. Very little investigation has been carried out on the epidermal ridges of palms in mental defectives except in the case of mongoloid imbeciles, where Cummins (1939) and Workman (1939) have investigated the main patterns. Penrose (1949) has measured the angles subtended at triradius t by triradii a and b, and the present writer has counted the epidermal ridges between the a and b triradii.

Comparison of different tests performed on the same individual is of value in showing whether tests purporting to be testing the same properties are, in fact, doing so, and also in determining whether certain psychological characteristics tend to occur concurrently in the same subjects. Previous work (Rudolf, 1948) has shown that the accumulation of general knowledge based on the environment and excluding school work, as shown by the I.Q. obtained by the use of Kent's test, correlates highly with the I.Q. obtained by the use of the Stanford Revision of the Binet-Simon, the coefficient being + 0·7499 ± 0·019. With a test of reasoning, Raven's Progressive Matrices (Group), the correlation-coefficient of the Kent Test was less impressive, being + 0·2686 ± 0·038. These results suggest that the accumulation of knowledge of the environment is not markedly dependent on, or connected with, the powers of reasoning.