The problem of differentiating, in patients of the pre-senile age group, the degree and quality of intellectual impairment that is due to depression from that which is brought about by some organic, cerebral deterioration is one of some practical importance. It is, in fact, as Henderson and Gillespie (1950) stress, an important point to determine with regard to the prognosis of depressive cases of this age” whether or not there is any complicating organic process causing a failure of memory and efficiency. If such is present then the prognosis must be viewed much more gravely than would otherwise be indicated.”

Most of the classical reviews of narcolepsy were written in the decade from 1925 (Kinnier Wilson, 1928; Redlich, 1931; Thiele and Bernhardt, 1933; Daniels, 1934, and others). The clinical picture was well established by these writers and does not need discussion. In addition to narcoleptic seizures, other symptoms are common, the most frequent being attacks of loss of tone and power, variously called cataplexy, “Lachschlag,” “Tonusverlust.” Night sleep is often disturbed by periods of wakefulness and bad dreams. During the phases of going to sleep or waking up, temporary paralysis of the muscles, without disturbance of consciousness, and hallucinatory episodes of all sense modalities sometimes occur. The generally accepted explanation of these various phenomena is that they represent a dissociation of the motor, sensory and central components of sleep. There are, however, three controversial points: firstly, the relationship of the patho-physiology of the seizures to epilepsy; secondly, the “somatic constitution “of the narcoleptic patient; and thirdly, the nosological status of narcolepsy.

The starting-point of the line of thought to be pursued here was some work reported in detail elsewhere (Roth, 1951), on the changes in the electrical activity of the brain produced by electro-convulsive therapy. When the findings were related to the known clinical and physiological effects of E.C.T. three converging lines of evidence could be discerned:

(1) The Changes in the Electrical Activity of the Brain Produced by E.C.T. and their Significance.

The subject of this investigation is the study of the immediate mental changes after standard leucotomy up to a time when the more acute manifestations of the brain operation have subsided and a stage of stabilization has been reached. Altogether twenty cases were examined, most of them schizophrenics. The observation time was between eight weeks and twelve months. The patients were examined in the first eight to ten days every day, and later at longer intervals according to their stabilization. In about half of the cases a detailed assessment of the patient's personality and intellectual faculties with a battery of tests was made before the operation. An assessment was also made of the patients' special abilities and knowledge, their general outlook and interests that had not been covered by the routine testing. The aim of the investigations was first to obtain a detailed picture of the acute condition following the operation, generally referred to as a confusional state, and to follow up the reorganization of these defects. Our next objective was to find out what significance these initial changes, or particular components of them, might have on the final result of the operation.

The first paper in this series described a number of experiments on a single subject, carried out to investigate an anomaly observed during performance of the Kohs Blocks test. This anomaly consisted of making the model correctly but rotated. (Illustration 1.)

The first hypothesis adopted to explain this observation was that anomalies of perception are functions of disturbed figure-ground relations (Goldstein and Scheerer, 1941). This hypothesis is not precise enough to permit a deduction which would make possible an exact experimental test, i.e., a deduction defining the conditions which would produce a measurable change in the rotation phenomenon. It was therefore necessary to arrive at more definite ideas about figure-ground relations. Such ideas were found in three hypotheses developed by Goldstein and Scheerer (1941) to account for variations in speed of carrying out the Block Design test. The first of these is that the square orientation (e.g., Cards a and b in Illustration 2) of a figure would tend to diminish the frequency of appearance of the anomaly, while the diamond orientation would increase it (e.g., Cards c and d in Illustration 2).

Electrical stimulation of different areas of the human brain has hitherto been confined to experiments with the brain in situ, in living subjects. It has been carried out while the brain received its blood supply from normal sources. By chemical analysis of the arterial and venous blood and measurement of its rate of flow, information has been obtained on how metabolic changes in the brain vary with changes in its activity. However, these conditions can give information only about gross biochemical changes associated with stimulation; they are cumbersome, and would not indicate abnormal reactions in small areas. Also, they detect differences only in substances which are actively exchanged with the blood stream.

This report of about 150 children is based on recent experience gained in the Maudsley Hospital Children's Department, in which epileptic children are investigated at special sessions. Most of the patients were examined in the usual way on their first visit to the Department. A full psychiatric history was taken from the mother or other relation. Intelligence tests, electroencephalogram (E.E.G.) and physical examinations were carried out. Later, as indicated, further special tests, such as air encephalograms, were done.

It is important to note the type of patients discussed in this report, in view of the notorious difficulty of obtaining reliable statistics in such a subject as epilepsy, whose manifestations are so varied that any one hospital or clinic cannot expect to see a truly unbiased sample. Children referred to the Maudsley Hospital nearly always show some behaviour disorder, but lack gross neurological signs and symptoms. Even in the case of epileptics a behaviour problem is frequently the presenting complaint, the actual seizures being a secondary problem. As the facilities for investigation are better than in many other clinics, cases are frequently referred from other hospitals for special investigation. This material, therefore, is undoubtedly heavily weighted by epileptics with behaviour problems. There are, on the one hand, disproportionately too few mentally normal children with epilepsy, and on the other, too few with epilepsy in association with grosser neurological disorders. No attempt is made, therefore, to give any statistics on the incidence of a particular symptom or sign within this group, as it is meaningless in relation to the whole body of epilepsy in children. The recent outstanding book by Bridge (1950) gives a very fair picture of epilepsy in childhood.

The aetiological factors may be divided into two groups: those within the social situation and those within the child.

While the main syndrome of tetany arising from hypoparathyroidism is widely recognized, it is doubtful if a sufficiently comprehensive view has been taken of the extensive range of manifestations which may be presented. The underlying pathological mechanisms may also be complex, and the circumstances under which hypoparathyroidism may develop are not always self-evident. Lyle (1949) attempts to classify hypoparathyroidism on an aetiological basis, and distinguishes postoperative, intrinsic, extrinsic, and idiopathic types. In our paper we are mainly concerned with tetany following thyroidectomy, the incidence of which has been estimated by Bell and Bartels (1951) as 2·9 per cent., based on their observations of 2,000 consecutive operations. The case which we are going to describe is one in which a history of thyroidectomy did not immediately appear significant in relation to the presenting features. Admission to hospital followed the onset of a psychotic illness, which in itself did not indicate any underlying organic disturbance, despite an account of an occasional epileptic attack some time previously. The latter feature, however, led to routine E.E.G. investigations. These are of particular interest in this case, especially as some of the recordings had been made before the diagnosis of hypoparathyroidism was established, and before the significance of the fits in the clinical syndrome was appreciated.

Recent statistics of old age mental disorder have drawn an alarming picture of rising rates of admission to mental hospitals in many parts of the world. One of the predictions made on the basis of such statistics has been that old age psychoses might, in due course, relegate schizophrenia to second place in number of admissions. There are, however, dangers in drawing conclusions about a complicated problem, such as mental disorder in old age, on statistical grounds alone. Before the figures can be properly evaluated more detailed information about the social, economic and, above all, clinical aspects of the problem will be required than is available at present.

This investigation deals with the measurement, by a peripheral method of discontinuous spectroscopic oximetry, of the arterial blood oxygen saturation levels in a group of schizophrenic patients undergoing insulin coma therapy.

The association between tissue anoxia and insulin hypoglycaemia was first established by Campbell and Dudley in 1924. Dameshek and Meyerson (1935), using the arterio-venous oxygen difference method with the internal jugular vein as the source of venous blood, showed that the injection of insulin in coma doses was accompanied by an anoxaemia in the schizophrenic patients they studied. This work was confirmed by Himwich, Bowman et al. (1939), and in another paper Himwich (1951, p. 277) and his co-workers found that the correlation of progressively developing clinical symptoms with the decrease of cerebral oxygen uptake was a closer one than the correlation with the more acute fall in the blood-sugar curve. An important symptomatic aspect of insulin hypoglycaemia includes the progressive changes in the levels of consciousness accompanying the approach towards coma. Wilder (1943) has outlined some of these changes, and Frostig (1940) and Himwich (1951, pp. 258-265) have delineated these awareness thresholds and discussed their relationship to the Hughlings Jackson theory of the phyletic organization of the central nervous system. Thus, during the first hour following insulin injection, somnolence and lassitude appear to be associated with suppression of cortical and cerebellar activity; in the second hour further clouding of consciousness, sometimes with excitement, perceptual disturbances, periods of confusion, exacerbations of previously existing hallucinations and latent psychotic syndromes are seen; in the third hour motor restlessness and loss of consciousness suggest the release of basal ganglia and hypothalamus; in the fourth hour deepening stupor and depression of exteroceptive sensitivity indicate a probable release of the midbrain and suppression of pyramidal function; in the fifth hour the deep pre-mortal coma presages medullary release. Similarly, it is with awareness changes that many workers prefer to diagnose the “real coma” level in a patient under treatment. Thus Sakel (1937) held that coma was to be diagnosed when no further personal contact with the patient was possible, and Kalinowsky and Hoch (1946) agree that the real coma level is reached when it is completely impossible to awaken the patient.

In the first part of an experimental study of learning impairment (Hall and Crookes, 1951) the present writers described some of the distinctive features of the performance of schizophrenic and organic patients on two learning tasks. Brief reference, by way of introduction, was also made to studies of learning efficiency in psychoneurotic patients which were carried out by Zangwill (1943, 1946) and Trist (1941). These writers, and also Davis (unpublished), noted particularly some of the reactions and types of failure that neurotic patients sometimes show, with special reference to the Rey performance test. Certain reactions to the test were felt to be characteristic, for example, of patients with anxiety states or hysterical reactions, although none of the writers had carried these observations further or confirmed them experimentally.

Temporal arteritis, also called giant cell arteritis, or cranial arteritis, was first described in 1932 by Horton and Magath. This syndrome is caused by a reversible inflammation of the cranial arteries, especially the temporal arteries (which are visibly inflamed), causing headache, mental and neurological disturbances as well as general toxic signs, and almost always occurring after the age of fifty-five years.

Pathology.—In the arteries involved there is a subacute inflammation of the adventitia and media with focal necrosis of the media, fragmentation and destruction of the internal elastic lamina with gross hypertrophy of the intima, often leading to occlusion of the vessel. In many cases giant cells are found in the media. Besides the cranial arteries other vessels are sometimes involved, e.g., the carotids (Scott and Maxwell 1941; Gilmour 1941), subclavian, coronary and femoral arteries (Cooke et al., 1946), post-auricular (Dick and Freeman 1940).

Aetiology is unknown. There is no evidence of tuberculosis or syphilis. A low-grade bacterial or virus infection of the arteries has been postulated, but repeated bacteriological examinations of the biopsied arteries have failed to isolate any organisms. The predilection which the condition shows for the temporal and cranial arteries is unexplained.

Any patient who shows a regularly recurring change of mental state will be of particular interest to the research worker, for in the recurrence, by acting as his own “control,” the patient provides the best of all comparisons.

Such a patient, a woman aged 39, provided the basis for this work. Usually sensible and well spoken, she would, about every twenty-first day, become confused and incoherent. Convulsive therapy (E.C.T.) always caused an immediate improvement, and within two or three days she was well again. (Previous experience had established that the confusion had little spontaneous tendency to recover.) As she provided this regular cycle, a systematic investigation was made over several months into those aspects more particularly relevant to the effect of E.C.T. on the adenohypophyseal-adrenocortical system, for a previous study (Ashby, 1949) had suggested that E.C.T. might owe its effectiveness to action through this system.

The purpose of this paper is to draw attention to results achieved in selected neurotic cases treated by short-term abreactive techniques in St. Clement's Hospital during recent months. Patients usually stay in for about two months; as yet it is too early to assess long-term results of this form of treatment, but it is felt that some of the initial results are extremely encouraging.

The fact that electrical stimulation of the brain can produce unconsciousness in man and animals has been known since the eighteenth century, and from time to time this knowledge has been used in the production of anaesthesia for surgical purposes; Hobday, in 1932, performed castrations and herniotomies in small animals under electrical general anaesthesia, and in 1935 Hertz used electrical anaesthesia for laparotomies in dogs. To-day electrical stunning is used in bacon factories with the object of rendering pigs unconscious before slaughter. Electroconvulsant therapy (E.C.T.) is widely used in mental hospitals for the treatment of certain conditions, and recently Freeman (1948) has modified this technique to produce surgical anaesthesia for prefrontal leucotomy.

In some instances electrical anaesthesia has proved satisfactory, but there have been reports of “distorted consciousness” after E.C.T. in human subjects (Morgan, 1950), and of electrical curarization after industrial accidents (Hume, 1935); in these conditions the subject is conscious of sensation but unable to make voluntary movements. Such a condition is only appreciated when the subject is questioned after regaining full consciousness, and hence, if it occurred in animals, it would not be readily recognized.

The object of the work described in this paper was to determine the effect of the many variables of electric stimulation, and to investigate the state of consciousness of human subjects and animals after electric stunning. It was hoped thus to provide a basis for future work on electrical anacsthesia and to acquire a better understanding of the action of E.C.T.

The assessment of pain perception is a subject of great importance from both the practical and the theoretical aspect. The increasing use of curare-like drugs as muscular relaxants and basal anaesthetics (Mushin, 1951), and in conjunction with electro-convulsant therapy (E.C.T.), has made the orthodox tests for depth of anaesthesia unreliable because they depend on the activity of voluntary muscle. E.C.T. itself (Morgan, 1950) and industrial electrical accidents (Hume, 1935) have given rise to unusual states of consciousness which cannot be fully understood until more is known about the way in which electric shock affects the central nervous system. On the theoretical side many explanations of the essential features of a state of consciousness have been given, but none of them accounts completely for all the observed phenomena; investigations designed to improve methods of assessment should provide useful information which, when correlated with that from other fields, may ultimately lead to a better understanding of the conscious state. The object of the experiments described in this paper has been the development of tests which will indicate the level of consciousness, and in particular the appreciation of pain, when the voluntary muscles are paralysed.