The group of mental disorders classified at present under the name of “schizophrenia” or “dementia praecox” offers a number of symptoms of not entirely “psychological” nature, and a more organic line of approach to the examination of these signs.

For many years the need has been felt for a means of measuring in a reasonably accurate manner the amount of deterioration present in mental patients.

The old criterion of saying that a patient is well because he is capable of working well in the laundry or garden or doing skilful work in the handicrafts department, combined with giving an impression of recovery to the doctors and relatives, is not accurate enough for modern standards.

May I apologize in advance for the many deficiencies of the paper I am about to read. I have not had the time that I would have wished to spend upon its preparation, nor the opportunity to make myself more than superficially conversant with the increasing literature, and I trust that you will excuse such imperfections as will appear.

The value of electrical shock therapy is becoming increasingly recognized and used by psychiatrists in the treatment of depressive states, particularly of the involutional period, states of depersonalization, and to a lesser extent in schizophrenia. One of the major objections to its use, however, has been the complication of fractures, generally crush fractures of the bodies of the mid-dorsal vertebrae (thoracic 4-8), and uncommonly that of limb bones, such as the femur. Another aspect of this problem arises with the occasional case in which the use of shock therapy is desirable, but a previous fracture of the spine or limb bones, or marked bone disease with an increased liability of fracture resulting during treatment, acts as a deterrent to the physician. Even more so is the question of continuing treatment without further damage to the patient, should a fracture have unfortunately resulted before the full course of convulsions is completed. Various methods have been introduced to minimize or abolish the muscular pull producing fractures, including intravenous injections of curare, of concentrated magnesium sulphate solution, or of beta-erythoidin hydrochloride; spinal anaesthesia has been similarly employed.

Seven hundred Progressive Matrices records of male neurotic military patients admitted to Sutton Emergency Hospital between April and November, 1942, were compared with a control group (1). The distribution of the patients' scores shows a negatively skewed curve with a clustering of scores below the control median (Fig. 1).

Although much work has been done on the physiological concomitants of affective states, nothing is known of any objective bodily changes accompanying thought processes, and yet the most superficial observation of lip, facial and eye movements, of unconscious gesture and restlessness furnishes indications of some of the more obvious somatic accompaniments of non-emotional mental activity.

When von Meduna in 1935 introduced convulsion therapy, his hypothesis that schizophrenia and epilepsy were incompatible diseases suggested that convulsion therapy was applicable only to cases of schizophrenia. Similarly, Sakel, when introducing insulin shock, proposed it as a treatment to be applied essentially to schizophrenia. It is thus not surprising that most psychiatrists at first devoted their main attention to comparing the results obtained from treating schizophrenia by these alternative methods of “shock” rather than in studying their effects on other forms of psychosis. However, Low and co-workers (1) in 1938 reported having obtained very encouraging results from giving metrazol-induced convulsions to a group of sixteen manic-depressive cases, and very shortly afterwards Bennett (2) issued a preliminary report on ten cases of the depressive psychosis in which he stated he had found a remarkable improvement following cardiazol convulsion treatment.

The range of psycho-pathological conditions for which the term “fugue” has been used has increased considerably and is still increasing. Originally the term was chosen to denote transitory abnormal behaviour characterized by aimless wandering and more or less marked alteration of consciousness, usually but not necessarily followed by amnesia. At present it is used for a variety of different symptoms, some of which have little in common; the psychiatrist using the term has to define what kind of fugue he means if he wishes to avoid misunderstanding and confusion. The reasons for the great popularity of the term are manifold. It is short, handy, vague, and has even a distinguished foreign flavour. But there are other reasons apart from those virtues. When the psychological mechanisms underlying abnormal behaviour were first studied two were regarded as responsible for the origin of fugues: dissociation and escape. From that time dates the tendency to describe as fugue nearly every condition of transitory alteration of consciousness which can be understood as the result of those mechanisms. Thus a remarkable change of conception has taken place; while the term “fugue” originally described a certain type of abnormal behaviour characterized by running away and wandering under a strong impulse and associated with clouding or narrowing of consciousness, it later came to be used, in addition, as the description of various results of the psychological mechanism of escape, without regard for the resulting behaviour. Obviously the fact that fugue means escape invited that change of conception. Considering the grèat number of neurotic and psychotic symptoms in the origin of which the two mechanisms mentioned above are supposed to play a part, there are hardly any limits to the use of the term. It is not intended to survey the whole literature on what has been called fugues; a few instances from current text-books and recent articles will demonstrate for how many conditions the term has been used in recent years.

In 1938 Wespi (1) in Germany and Stalker (2) in this country reported cases of crush fracture of the spine following cardiazol convulsion therapy. It was not until then, some four years after its introduction, that attention was focused on the risk of fracture in this form of therapy. During 1939 alarming reports appeared, especially in the United States, regarding the occurrence of such mechanical injury. Polatin et al. (3) radiographed 51 cases following metrazol convulsive therapy and reported spinal fractures in 43 per cent. Bennett and Fitzpatrick (4) in a similarly treated series of cases recorded 47 per cent. spinal fractures. However, the latter figure was obtained from a series of only 18 cases, and should therefore be accepted with reserve. In this country H. A. Palmer (5) in a series of 20 cases treated by cardiazol shock therapy found spinal fractures in no less than 5 cases (25 per cent.).

Damage to the frontal lobe is liable to produce personality changes; it is highly probable that lesions have to be bilateral to have this effect. But beyond that, there is little agreement about type, extent and localization within the frontal lobe of the lesions which are followed by personality change. Little is known about the different types of clinical picture caused by bilateral frontal lesions. In a certain proportion of the cases euphoria is the most impressive symptom, and it is for this reason that operations on the frontal lobes have been proposed in the treatment of depressions. (Lit., see Hutton.) The value of the procedure is still under discussion, and its theoretical foundation is far from being understood. This is not surprising, for if one tries to analyse such an operation, one has to take into account at least four variables: the patient's previous personality, his mental illness, the psycho-physiological effect of the lesion, and the psychological effect of operation, nursing care and environmental changes. The cerebral factor is obviously the most interesting one; to judge its importance one tends to interpret the operative results in the light of experience after other frontal operations or injuries.

Re-examination of the various problems arising from psychoses following childbirth is of interest for various reasons. Firstly, their place in the system of psychiatry is far from clear; their original description under the term “puerperal insanity” (Kraepelin) had given rise to the idea that they represented a clinical entity. According to Kraepelin the great majority of these psychoses take the form of catatonic states and only a few are of the manic-depressive group. More recent investigators, however, have shown that there is no psychotic reaction peculiar to childbirth (Clarke, Kilpatrick and Tiebout, Zilboorg, Saunders, James, Strecker and Ebaugh, Harris, Karnosh and Hope, and Piker). In these contributions the importance of the accompanying environmental and sociological factors has also received consideration.

In the early days of convulsion therapy many chronic psychotics were treated by this method in the hope of effecting a cure. While temporary improvement was achieved in most cases, results were disappointing, owing to the rapidity with which relapses occurred. With cardiazol as the convulsant, various complications, such as sclerosis of veins, tachycardia, vomiting and, most of all, aversion to the treatment on the part of the patient made its continued repetition impracticable.