Introduced in 1933, Sakel's pharmacological shock treatment [Sakel (1935a, 1935b, 1938)] is now regarded as a valuable method of treatment in schizophrenia. The complications which may ensue during the treatment are, however, both numerous and dangerous, and may be classified according to the system predominantly affected as follows:

1. (1) The Respiratory System.

2. (2) The Cardiovascular System.

3. (3) The Nervous System.

The usual leucotomy cut in this country, made through burr holes orientated by means of skull measurements, in the majority of cases enters the brain at about the middle of pars triangularis of the inferior frontal gyrus (Brodmann's Area 45), and if performed in a strictly coronal plane remains entirely within the prefrontal region. Intentionally or unintentionally cuts are not infrequently placed either anterior or posterior to this plane. That cuts made posterior to strictly prefrontal levels are often followed by an unfavourable post-operative course distinguished by particularly severe personality change, persisting incontinence, vasomotor, trophic and neurological disturbances has been demonstrated by Knight (1943), Meyer and Beck (1945), Ziegler and Osgood (1945), Reitman (1946) and others.

My interest in this subject was aroused during the first few weeks of the campaign in Normandy, when seemingly large numbers of these cases were known to be undergoing surgical treatment. At that time the rapid flow of psychiatric cases prevented a clear view of the significance of the situation as it was impossible to know accurately whether these wounded were in high proportion to the number of troops in action or to the total of battle casualties.

The cases reviewed in this paper were treated in Three Counties Hospital during the last seventeen years. The ages of the patients ranged between 15 and 44 years. Of the total 1,009 cases, 563 had insulin coma and convulsion therapies, while 446 received no such special treatment. Some had prefrontal leucotomy after failing to respond to insulin and convulsion treatments, but their number is small and they are not included here.

The pattern of the epileptiform fit produced by electric shock treatment is fairly uniform and constant. The four stages of the fit—the preconvulsive, tonic, clonic and post-convulsive phases—are characteristically expressed in postures and movements of eyes and head in each phase.

Kraepelin (10) in 1908 first defined a group within his classification of schizophrenia which he described as periodic catatonia. The clinical features of this type may be briefly summarized. The onset, usually between 14 and 20 years, is frequently characterized by a period of erratic conduct followed by an interval of stupor, confusion or excitement, which thereafter undergoes periodic remissions and relapses. The periodicity is remarkable in the rapidity with which all changes occur. In the periods of remission the patient is free of catatonia and associated symptom-complex (sympatheticotonia), but is still dull, apathetic and withdrawn; he often recalls events from the reactive phase, but without insight. The patient is still schizophrenic, with emotional flattening and poverty of ideation, and remains so throughout. In the reactive phase the picture is one of catatonic stupor or excitement, with clinical evidence of sympathetic over-activity.

Denial of knowledge of personal identity is occasionally encountered in various mental disorders. Temporarily present sometimes in hysteria, in schizophrenic psychoses it is expressed as a delusion that identity or name has been altered, and it may be a feature of the depersonalization syndrome. Seniles may maintain that they do not know or have forgotten who they are.

Inability to dress oneself is a rare symptom in focal brain lesions. We have observed it in two cases, a tumour expanding between the cerebral hemispheres, and a case of head injury in which the mental condition was sufficiently intact to allow a detailed analysis: In discussing the imperception phenomena of the tumour case, we have referred to certain others of relevant interest.

A subject such as this is much too large to deal with at all fully in a short paper. As it is designed as a preparatory review of this topic as it applies to Great Britain, the subject being dealt with at the International Congress of Mental Health by delegates from overseas, I am placing the emphasis on the community rather than on the aggressive child. It is necessary, however, to consider what the aggressive child does to the community and why, in addition to discussing what the community does to the aggressive child, and the reason for this.

Treatments for enuresis have been legion, but several authors have recorded beneficial results from the use of ephedrine hydrochloride.

Knowledge of amnesia is dependent upon the subject's statement. He can tell us what he will. If he has studied the subject well, he can mislead us. He may have motives for fabricating. He may benefit, he thinks, financially, socially or in other material ways, by inventing an amnesia. A history of grave injury may produce avoidance of danger or of unpleasant work. A medical history, which the patient may think unusual, may give him prestige or sympathy. Finally, he may invent an amnesia to give the doctor a good story or to “pull his leg.”

Obsessional symptoms and depression often co-exist. There are obsessional neurotics who are subject to recurrent depressions, and there are patients with marked obsessional personality features, but not suffering from an obsessional neurosis, who develop severe obsessional symptoms in the course of their depressions only. I do not agree with those writers who maintain that the typical features of the obsessional character can be found in every case of manic-depressive illness.

From the available literature it appears that inhalational abscess of the lung following E.C.T. is a rare condition, but it is difficult to assess the actual incidence. Cook (1944), in his extensive review of the subject, quotes Meduna and Friedmann (1939) as stating that lung abscess occurred in 0.1 per cent. of cases, but this probably refers to patients undergoing metrazol convulsions, in whom there is an additional risk of embolic abscesses due to mobilization of thrombus at the site of injection. Jessner and Ryan (1943) mention that aspiration pneumonia may complicate metrazol treatment, and that pulmonary abscess may occur as a result of old pelvic thrombo-phlebitis or from mobilization of thrombus at the site of injection. They do not refer to inhalational lung abscess complicating E.C.T. Sargant and Slater (1944) state that chest complications are rare after convulsion treatment. Kraines (1943) and Brain and Strauss (1945) do not discuss the condition. Vassallo (1946) in an unpublished series of over 300 cases has observed one inhalational lung abscess. Kalinowsky and Hoch (1946) say: “The development of pulmonary diseases during treatment is rare in E.C.T., but was quite frequent in metrazol therapy.” They mention some possible reasons for this, e.g. abscess due to mobilization of thrombi at the site of injection. They add: “The literature on E.C.T. contains only one case of pulmonary abscess” (Kalinowsky and Werthing, 1943). The paper quoted, however, merely states, that the patient developed a lung abscess which was successfully treated with sulphanilamide. All authorities agree that pre-existing lung disease, and especially tuberculosis, is a strong contra-indication for E.C.T. Since there are so few references to this illness in the literature it seems profitable to describe a case.