There has recently been a plethora of new methods of psychosurgery. This has, we believe, created considerable bewilderment in the minds both of the clinical psychiatrists who have to decide which of the methods to choose and of the neurosurgeons who have to practise them. The aim of the present paper is to clarify and disentangle the situation as far as this can be done from the anatomical angle.

The theory that physique and temperament are correlated remains a subject of controversy. Various workers in the field differ in their findings and, in the past, investigations on body build and its psychological correlates have been handicapped by lack of precise knowledge of the variations in body build. In recent years improved statistical methods of analysis have been applied to the study of body build, enabling the variations in physique to be analysed and assessed inductively.

The interest in developmental abnormalities and their aetiology has considerably increased in recent years. In spite of this, there is a paucity of information about congenital anomalies of the teeth and about their association with similar lesions in other parts of the body.

From time immemorial man has tended to classify his fellow beings into physical types associated with specific disease susceptibilities or characteristic mental or moral qualities. The ancient Hindus described three types of human physique likened to the elephant, the bull and the deer. Hippocrates formulated a dichotomy in build with a narrow type, the habitus phthisicus as one extreme and a broad type, the habitus apoplecticus, as the other.

The past ten years have seen a spectacular increase in the number of psychologists who have elected to take up the type of work usually referred to as “clinical,” This increase has been most marked in the U.S.A., where now some 25 per cent. of the members of the American Psychological Association are employed in this field, and where Government regulations and training schemes set up under the V.A. (Veterans' Administration) make it almost certain that within a few years clinical psychology will constitute the main field of employment for psychologists (1). In Canada, too, there has been a similar growth, leading to all the problems of registration and certification which are currently being tackled in the United States (2). In this country, while psychologists have occasionally been employed in hospitals for the mentally ill, the development of “clinical psychology” in any formal sense may be said to have started in 1947 with the foundation of the Psychological Department at the Institute of Psychiatry (Maudsley Hospital), one of whose objects was to give a course of training in clinical psychology to graduate students of psychology (7).

One's approach to transorbital leucotomy must be critical for many reasons, chiefly that it is another blind operation with all the deficiencies this signifies. Meyer and McLardy have demonstrated the variety of anatomical sites in which lesions may be found following prefrontal leucotomy, and have stressed the variability in the position of the underlying cortex in its relations to the bony landmarks of the skull. Once more, sweeps are to be made with a blunt instrument, and the differing consistency of the brain, and perhaps its movement, will make it impossible to be certain whether the lesion produced is the size intended and in the position calculated. The dangers of intracerebral haemorrhage exist as before, and, in addition, because of the site of entry, there are chances of introducing infection, of cerebral rhinorrhea resulting from damage to the frontal sinuses, and of raising bone spicules from the orbital plate. More recently McLardy has said that with the addition of the deep frontal cut, were the caudate nuclei to be damaged bilaterally, restlessness, persisting incontinence and “delayed operative death” might occur, as may follow posterior cuts in prefrontal leucotomy.

The Thematic Apperception Test (TAT) of Murray first appeared in 1935; it consists of a series of pictures on cards, 20 of which are shown to the subject with an injunction to make up a short story based on what the people in the pictures are doing, thinking or feeling, and what he thinks the outcome will be. The theory is, of course, that the subject will “project” into his responses his own attitudes, moods, drives, desires, etc., and the TAT has for this reason been called a fantasy test (Masserman, 1947). Elaborate scoring methods have been developed with a high degree of inter-examiner correlation (see Murray, 1938; Rapaport, 1946; Rotter, 1940; Tomkins, 1947; Wyatt, 1947), but they are rather too complex and time-consuming for ordinary clinical purposes and all too often the examiner may fall back on a method of intuitive interpretation, evaluating responses in the light of his psychopathological knowledge and experience—that is, using experience derived from free association in a situation that is designed primarily to produce a controlled associative process. It would not, of course, be the first time that a scientific solecism had been the means of justifying a therapeutic end, but here there are two logical errors. First, the facts are being selected to fit the theory, and as Harrison (1943) says, “the analyst may project into his interpretations his private personality theories or even his own personality”; second, the experimental findings are not being evaluated against normal controls. The intuitive method is thus seen to be personal, subjective and unstandardized. The aim of psychometrics, however, is the measurement of personality factors, and measurement, says Carr (1925), must be “impersonal, objective and standard.”

During the past few years interpretations of drawings for the assessment of intellectual and emotional aspects of personality have been used frequently. Various scales have been designed on the basis of a correlation between the elaboration and complexity of a drawing on one side, and the intellectual capacity, as measured by orthodox intelligence tests, on the other side. The best known of these scales is Goodenough's “Draw-a-Man” test (13), which has been used extensively.

1. It may be well to begin by delimiting the term psychotherapy; to me it has two aspects:—

(a) It is a procedure of verbal interchange between patient and doctor in which the phenomena presented by the patient to the doctor during interview are interpreted by the doctor to the patient—to the end that the patient's mental pain shall be relieved (by the interpretation) and he shall have an increased understanding and mastery of the impulse-laden, unresolved, emotional conflicts in his own personal past experience, and a better insight into his own personality.

Before the the last war psychological tests were not much used in mental hospitals, as there were few tests suitable for adults and, for that matter, hardly any trained clinical psychologists in the country. The “Binet” test or some modification of it was most commonly used, but it is unsatisfactory for adults, and now redundant. The war produced a considerable number of reliable adult tests, standardized on large samples of service men and women, and, although the effective age-range was restricted by service requirements, the tests are a great improvement on pre-war material, and a welcome addition to the clinical psychologist's stock-in-trade.

The period of adolescence includes within its span the shorter phase of puberty, and may extend from prepuberty as early as ten years (1) to adult maturity attained perhaps in the early twenties. A study of psychosis in adolescence must therefore take cognizance both of the psychoses of later childhood and of early adult life.

Though it is now generally accepted that prefrontal leucotomy has an effect on the subject's behaviour, its mode of action and the intermediate stages of its effect are still obscure. Some evidence, which has been sufficiently reviewed elsewhere (Meyer and McLardy, 1949; Fleming, 1944), suggests that the operation acts by lessening emotional drive: the retrograde degeneration which usually occurs in the dorso-medial and anterior thalamic nuclei points to this. Clinically, however, the belief rests on little more than impressions. In order to obtain more objective evidence, we have used the psychogalvanic response, not because it measures emotional change with fidelity, but because it is one of the few objective tests available. Though its precise relation to emotional change is still not clear, that it does have some relation has been demonstrated repeatedly. We have therefore attempted to compare the sizes of the response before and after the operation.

The term “therapeutic factor” will be used to denote any agency which is potentially capable of producing such changes in the personality of a patient that an alleviation or cure of clinical symptoms may result. Such agencies originate either in the environment of the patient or in his organism. In psychotherapy we are primarily concerned with environmental agencies, namely those which are introduced, regulated and controlled by the therapist, and which are therapeutic only if the patient responds to them in a manner that is conducive to producing the desired changes in his personality. We can therefore distinguish three elements in a therapeutic process: environmental factors, responses by the patient, and ultimate personality changes.

This study is part of an investigation into the physical and mental status of a small series of patients with duodenal ulcer undertaken at Guy's Hospital. Each patient in this series had a routine biophysical and biochemical investigation, a clinical interview and the Rorschach test. In addition, information about the patient was gained from other sources, such as his relatives and employer, and his behaviour while in hospital was kept under review. In a majority of the patients examined, phases of activity of the ulcer dyspepsia were correlated in time with crises in the patient's personal life. The Rorschach patterns from the records of these patients are presented here for comparison with those found in other disorders, and for the assessment of certain features common to this series.

The electrical method of inducing convulsions grew out of the use of convulsant drugs. Experience with E.C.T. has not proved that it is therapeutically superior to the chemical methods. One must, therefore, attribute the now almost universal use of E.C.T. to its technical and psychological advantages.

The purpose of this paper is to call to the attention of neurologists, psychiatrists and neurosurgeons a group of meningiomas with dementia as the earliest and presenting symptom. The diagnosis in these cases is apt to be missed, especially if the patient is in the arteriosclerotic or presenile age-group. This is equally true of other tumours, but the practical importance of early diagnosis of meningiomas is that with the removal of the tumour the patient usually recovers from the mental illness.