In spite of Freud's great discoveries tracing back the origins of adult psycho-neurosis to the mental conflicts of early childhood, until comparatively recently little was done by psychiatrists generally to investigate and treat directly the mental problems of difficult and neurotic children. Though a few clinics had been established for a considerable time in Vienna and elsewhere as a result of the work of Adler and his pupils, the “Child Guidance “movement obtained its greatest impetus from America. Here it arose, however, out of social problems rather than medical; more particularly from Healey's studies of delinquent children. Partly on account of its origin in this way, and partly no doubt influenced by the behaviourist psychology so much in evidence in U.S.A., the tendency there from the beginning was to stress the importance of the child's environment and the remedial effect of altering harmful influences found in it. The psycho-analytic schools, on the other hand, have emphasized the endogenous nature of neurotic conflict, i.e., localized the trouble wholly in the child's mind; which has led them to concentrate on treatment of the child itself to the exclusion of the material surroundings.

The concept of accident-proneness is by no means a new one; but the term has passed into popular use, and although the colloquial usage of the term is frequently incorrect, yet the idea that some people are more liable to sustain accidents than their more fortunate fellows is now widely accepted. Of late years psychologists have made it their business to inquire into the nature of this susceptibility to accidents, and have found that whilst mankind in general is characterized by this proneness, there are individual differences in the degree to which it is possessed. In any sufficiently large observational group it is usually found that most of the accidents are sustained by a minority of the members of that group, and it is obviously of importance to discover what are the personal qualities or lack of abilities which make this minority specially accident-prone.

In the extensive literature on sleep therapy some fifty complications have been recorded by the various authors. In a previous article (Journ. Ment. Sci., November, 1937) these were listed (pp. 660, 661) and divided into four main groups as follows:

1. 1. Common complications: Representing mainly normal by-products of the treatment.

2. 2. Complications involving particular tissues: Representing tissue idiosyncrasy.

3. 3. Accidents.

4. 4. True toxic complications: Representing a group which could not be regarded as either a necessary by-product of the treatment, an unavoidable expression of disproportionate sensitivity on the part of a particular tissue, or an accident which might be avoided.

Nicole and Fitzgerald's assumption in 1932 that the Wassermann test had at last passed to rest in the limbo of historically interesting experiments can hardly be said to be correct, and the test still remains to-day as the standard method for the sero-diagnosis of syphilis. At the same time the steadily increasing specificity of flocculation tests and their value as ancillary procedures cannot be denied, and the accepted diagnostic ideal is a parallel examination by one of these and by the Wassermann test.

During the last twenty-five years it has come to be recognized that a fairly large amount of mental deficiency appears to coincide with or result from faulty intracranial myelination. In some such children little or no post-natal development occurs, in others recession is already occurring at birth; a few remain fairly normal for some years. Spastic contractures, especially of the legs, grow progressively worse, epilepsy may appear, the child goes steadily downhill and early death is the usual termination. In some cases choreoathetosis is present, and this may either, if the patient lives long enough, disappear spontaneously, or, more usually, become impossible when the spastic contractures have immobilized the extremities. Post-mortem one finds one of two conditions—demyelination of the brain (the status dysmyelinatus of Hallervorden-Spatz) or hypermyelination (the status marmoratus of the Vogts). In both forms there is much hypergliosis, evidently secondary to some irritating but slow myelin poison which finally produces anoxia. Clinically during life both varieties appear much the same, and that is all that is known about its nature at present. Cases were recorded by the Vogts in 1920, Hallervorden and Spatz in 1922, Kalinowski in 1927, Helfand in 1931, Spatz and Peters in 1938; in this country by Meyer and Cook in 1936, Meyer and Earl in 1936. By these authors the views of others are summarized—Bielschowski, Loewenberg and Malamud, Urechia and Michalescu, Bouché and Van Bogaert, Casper, Ammosow, Bostroem, Bodechtel and Guttmann. If epilepsy has been present, it generally disappears after some years. By no means all cases end up as helpless idiots; some learn to attend to their own wants, but few ever walk freely.

On the subject of the correlation of neurological lesions with psycho-pathological phenomena, two eminent neuro-histologists, the Werthams, have recently written: “It must be pointed out that in proportion to the extraordinary complexity and differentiation of the finer functions mediated by the central nervous system, histological lesions are very gross. However we may conceive of the functional processes going on in the central nervous system—physiological, physico-chemical, metabolic, electrical, etc.—it should be obvious that only the grossest miscarriages and defects would become morphologically visible. Structural lesions are the effect of functional reactions that are not histologically demonstrable. Physico-chemical changes, metabolic processes, functional changes of blood-vessels, and similar biological phenomena that cannot be micro-histologically demonstrated, precede the anatomically visible lesions which occur only where the processes have attained a certain intensity. What we can demonstrate histologically in the nervous parenchyma is not by any means an adequate basis for the understanding of the quality, intensity or normality of nervous functions. In a patient who dies in the convulsions of tetanus, the anterior horn-cells may reveal nothing abnormal. Even the most minute and complete histological examination of the central nervous system in a case may fail to reveal any evidence of an existing profound disorder of brain function. There are cases of idiocy of the severest type in which no significant histological changes may be demonstrable in the brain.”

The stimulus behind this investigation was created by various factors which can only be enumerated briefly. In the course of routine sero-diagnosis of syphilis in psychiatric work at the Institute during the last five years, it became evident that, of the three flocculation tests employed, the Kahn (Kahn, R. L., 1928), Müller-Ballungs reaction (Müller, R., 1929), and Meinicke Klarungs reaction (Meinicke, E., 1929), the Meinicke original extract gave results superior in sensitivity. This feature was shown particularly in very early infections and treated cases. Three Wassermann tests, the standard method for psychiatry (Mann, S. A., and Partner, F., 1931), the Wyler drop technique (Wyler, E. J., 1929), and the Browning and Kennaway methods (Browning, C. H., and Kennaway, 1924), run concurrently, could not claim to be as good in this respect, and further, were liable to give non-specific results. The explanation of some of the anomalous reactions of one or another of the three hæmolytic systems seems to lie chiefly in the fact that sera from psychotic and mentally defective patients contain in larger degree elements that are prone to disturb specificity.

The electro-encephalogram (E.E.G.) is a record of the electrical potential changes of the brain as recorded by placing electrodes on the scalp without opening the skull. The technique is similar to that used in obtaining a electro-cardiogram, and in the apparatus shown three independent recorders are used, for reasons to be described later.

This method appears first to have been used in the U.S.A. by Kunde, Hall and Gerty (1927) and then by Mackenzie (1927) in this country. Later Driver and Shaw (1933) gave divided doses of typhoid vaccine, and Schnitker (1934) gave typhoid H antigen. T.A.B. vaccine, containing one thousand million dead B. typhosus and seven hundred and fifty million each dead B. paratyphosus A and B per c.c., has been used here since July 6, 1928.

Attempts to find a function characteristic of schizophrenia which may be correlated with the electro-encephalogram have not been very fruitful. For example, in a group of 60 adult schizophrenics only a very slight positive correlation exists between the electrical activity of the brain and duration of illness (Rubin, unpublished observations). The same correlation obtains for duration of hospitalization. Although not systematically studied, there appears to be no correlation between the electro-encephalogram and diagnostic sub-type of schizophrenia.

In any search for enteric carriers the patient with a positive blood-agglutination must be regarded as suspect. Earlier workers were of opinion that the converse of this was true—that a negative agglutination reaction implied that the case was not a carrier. It is true that McCowan and Mann (1925) described a series of nine carriers, of whom two showed a negative agglutination reaction during the clinical attack of typhoid fever, but the subsequent history of the agglutination reactions is not given. Ashby (1931) indicates in his series the prevailing belief that carriers show significant alterations in their agglutination reactions. Although repeatedly controverted in the medical literature by the publication of small groups of cases where the carrier state has been accompanied by negative blood-agglutination reactions, this view dies hard, and was revived during the recent discussions centring around the Croydon typhoid epidemic.

Since sulphanilamide has been shown to be of value in the treatment of infections due to a variety of organisms, it was thought that it might be efficacious against bacillary dysentery.

In round figures there are 11,000 epileptics in public mental hospitals, 3,000-4,000 in institutions for mental defectives, just under 4,000, who are neither insane nor mentally defective, in colonies and residential schools, and an unknown number, probably a considerable one, in public assistance hospitals and institutions. How many are living in the community is not known.

Since the passing of the Mental Treatment Act, 1930, 135 patients have been admitted to St. Ebba's Hospital up to date. An analysis of the first 30 patients admitted on a temporary basis was made by Dr. Wootton and myself, and the results published in the Journal of Mental Science for July, 1937.

It is generally agreed that the occurrence of marked clinical dementia and accompanying cortical pathological lesions is rare in cases of idiopathic paralysis agitans. Cases which show this association have been described by Jakob (1923), and by Critchley and Greenfield (1937.). The name “Jakob's disease “has been assigned to this clinico-anatomical syndrome by the latter authors. Our case is clinically a typical one of this syndrome, and possesses some unusual pathological features which make it worthy of record.

In this short paper I hope to present to you some of the problems attendant on the employment of the epileptic. In so doing I shall rely as far as possible on my personal experience of the problem as it has presented itself in my routine work as medical officer for the London district of the L.M.S. Railway, which covers a large area of our system, with some 44,000 workers employed on a wide variety of occupations.