Search

It is certainly noteworthy that, during the last few decades, whatever the contributory forces, more and more emphasis is being placed on the contention that man is a social being and that his individuality as a person is meaningful only in terms of his relations with others. Mead (1947) has shown that man as a social being is subjected throughout his entire individual existence to systematic cultural pressures which reinforce or intensify, elaborate or suppress his psycho-biological potentialities on different lines in different cultures. Cultural anthropologists and those psychiatrists who have been fortunate in working among peoples of different cultural institutions have laid down the hypothesis that cultural factors influence the aetiology and psychopathology of mental disorders.

1. A series of fifty -two chronic cases on whom prefrontal leucotomy was performed has been surveyed. over a period from nine months to two and a half years using the Sands and Malamud Rating Scale. A precise evaluation of the effect of leucotomy in each case has been obtained by comparing the post - leucotomy state with the premorbid profile. Scatter graphs for each item studied.- appearance, motor activity, responSivityy aggressiveness, socializ- ation, attention, speech, appetite, sexuality, sleep, work, mood, emotional tone, tension, awareness, ideation, thought content and memory - show the general effect of prefrontal leucotomy on symptomatology. 2. In the schizophrenic group of twenty -eight cases (ten hebephrenics and eighteen katatonics) there was one death, twc female patients are considered recovered, twenty patients show _ improvement ranging from moderate to good, one hebephrenic was discharged but relapsed, and four showy little or no change. Ail the patients in this group were of the destructive, aggressive and impulsive type and a general finding was that behaviour improved, they were less resistive and more amenable to nursing -management. In the affective group of thirteen cases here uere ten discharge , two of whom relapsed. Personality c an.ges in two cases have been noted. The patients who have not been discharged from hospital have shown some degree of improvement. There were two deaths in this group, one directly due to operation and another two years after operation. In the paranoid group of five cases four are considered to have made social recoveries The psychopathic group of three cases has shown a poor response to operation. One case of hysteria improved but, over a period of about six months, gradually developed a personality change. One epileptic was operated on but died,soon afterwards. 3. It is concluded that the effect of prefrontal leucotomy is to remove mental tension and that even in chronic deteriorated patients, improvement may occur. The association of mental tension with hallucinations and delusions and the effect of leucotomy on these features is discussed, but it has been noted that while the disturbed patients improve in some respects, there is little or ri? change in the basic features of schizophrenia. The view is expressed that prefrontal _leucotomy should be reserved for cases with a duration of illness of at least five years and where other methods of treatment have failed to produce improvement. Where good remissions of reasonable duration occur, prefrontal leucotomy is inadvisable.

History and Nature of Neurasthenia: Definition | Introduction by Beard | Earlier writings | Previous titles to condition neurasthenia a neurosis Illustrative Cases: A number of cases taken from a large number met with by writer The Causation of Neurasthenia: Increasing prevalence of neurasthenia | Heredity a cause | Predisposing and exciting causes | Effect of infectious and toxic diseases | Country and Climate | Age and Sex | Occupation | Intellectual, muscular, and emotional strain | Diseases of the Reproductive system | Abuse of Alcohol etc. | Diseases of the Throat and Nose | Dyspepsia Traumatism The symptoms of Neurasthenia: Difficulty of classification | Certain fundamental symptoms found in most cases | Headache | Insomnia | Nervousness | Gastric symptoms | Blood in neurasthenia | Circulatory Disturbances | Pulse | Urinary changes | Changes in the Sense organs | The sexual organs | The nervous system | Fears and anxieties | Henri neurasthenia | Various forms | Traumatic neurasthenia. The Diagnosis of Neurasthenia: Not an easy matter | Absence of physical signs | Coexistence with other diseases | Organic diseases of the brain and spinal cord | Hysteria | Hypochondriasis | Anaemia | Lithaemia | Petit Jal | insanity | Diagnosis of Traumatic cases The Etiology of Neurasthenia: Actual pathology unknown | Various Theories | The nervous theory | Gastric theory | Arguments for and against both | The two theories summed up | Glenard's theory | Anjel's theory | Views of other writers | The theories related to Traumatic neurasthenia Neurasthenia: Prognosis, Complications and Sequelae | Not a fatal disease | Gradual onset | Age of patient | Family history | Circumstances of patient | Certaint? of diagnosis | Neuralgias | Writer's Cramp and Chorea | Certain skin disorders | Insanity a sequela | Opium taking | Craving for Alcohol | Organic lesions | May drift into Hypochondriasis if left untreated. The Prophylactic Treatment of Neurasthenia: Importance of it | Must start early in life | Life in towns | Choice of a school | Home surroundings | Food | Sleep | Outdoor exercise | Moral Education | Puberty | Avoidance of Stress and Strain | Choice of Profession or Trade. The Treatment of Neurasthenia: General Indications | Views regarding-drugs | Importance of good surroundings during treatment | Each case to be considered seperately | Gain confidence of patient | Rest | Diet | Massage | Weir-Mitchell's treatment | Seclusion | Overfeeding | Duration of Rest cure | Hydro therapeutics | Various methods | Electricity | Views regarding it | Hypnotism | Drugs | Avoidance of Opium | Hypodermic Transfusions | Paul's method of treatment | Change of air and scene | Suitable companion.

1. An account is given of the administration of 2443 treatments by electro-narcosis to 152 patients, with special reference to the treatment of 105 vases of schizophrenia. 2. The history of the development of the method known as electro-narcosis is described. The description refers to the pioneer efforts of Leduc to introduce eiectrical anaesthesia, and deals with the experimental work on animals, in which Van Harreveld was the principal investigator. Work done on the types of current which may be used, and on the effects of electro-narcosis on cerebral metabolism and blood pressure, is summarised. An account is also given of investigations into the ineidenee and possible causation of cerebral damage following the passage of an electrical current through the brain. 3. The claims of other workers in the clinical field are set out; the lack or controls is commented on and the divergent developments in technique noted. 4. An account is given of the technique used to induce electro-narcosis, with special reference to refinements such as thiopentone premedication and movement of the electrodes. 5. The difficulties and dangers encountered are described, together with the methods of overcoming them. 6. A description of the survey of 557 cases of schizophrenia admitted to hospital during 10 years prior to the introduction of shock therapy is given, for purposes of control. 7. The results achieved after the use of electro-narcosis are set out and compared with the control group in a manner which contrasts groups of cases of similar duration of illness before treatment. 8. The value of advances in technique which diminish convulsive phenomena is discussed, and the importance of using thiopentone is stressed in this connection. The use of thiopentone is shown to have no adverse effect on therapeutic results. 9. It is argued that a doctor can treat at least twice as many patients by electro-narcosis as by insulin shock, in a given time. It is shown that the organisation of the treatment unit can be very flexible. 10. The difficulties involved in comparing two groups of schizophrenics are discussed, and the reasons for the method chosen are given. While the main emphasis is placed on clinical appraisal, the use of statistics in regard to measurable factors is defended, especially in regard to the duration of illness before treatment. 11. The electro-narcosis group is shown to be of intrinsically worse prognosis than the control group, as regards duration of illness before treatment. Yet the percentage of discharges after electro-narcosis is 41% as opposed to 35.2% in the control group. 12. Comparison of groups of similar duration of illness shows that the ratio of discharges after electro-narcosis to discharges in the, control group is approximately 5 : 3. 13. The Report of the New York State Hospitals' Commission (1944) is cited to show that the ratio of discharges in cases treated by insulin shook to discharges in a control series is 4 : 3. 14. Caution is suggested in comparing these results, especially as the former are short-term, while the latter are long-term. Emphasis is placed on the unwisdom of regarding electro-narcosis as a rival or possible successor to insulin shock treatment, but it is submitted that it has a useful place in the treatment of schizophrenia, especially where there is a shortage of medical staff. 15. The case histories of the 105 patients treated by electro-narcosis are appended in a reasonably abbreviated form.

by a series of fifty cases admitted to Ewell Mental Hospital during the last three or four years. These cases were not chosen on account of any special clinical interest, but are merely those among the Schizophrenic admissions during that period about which it was possible to obtain a fuller "life history", although even the best of these contain many regrettable omissions. These omissions, and the difficulty in general of obtaining the required information, emphasise the urgent need for some central authority equipped with psychologists, to record the personality and other facts of psychological import in the case of every child; to preserve these records until the occasion for their use might arise, such as ascertain - ing suitability for employment and, in the more unfortunate cases, for the convenience of the psychiatrist. As it is, there are only a few selected cases whose personalities have been scientifically studied from infancy onwards, and in such an investigation as this we can only hear a lay, and frequently biased, opinion and are left, in many cases, with inferences and not facts. The material for this study was obtained through the usual avenue of inter views with the patient's relatives and friends, and with the aid of reports from that very valuable assistant - the Social Worker. For convenience in tabulating results etc., I have made a rough division into "age groups ", the first three years being considered as "Infancy "; from four years to a period corresponding to puberty, usually between twelve and fourteen years, as "Childhood "; and from there to the late "teens ", the exact age depending on individual circumstances, as "Adolescence "; and the remaining period as "Adult" life. Environmental circumstances are bound to differ to a considerable extent in a qualitative fashion in these different periods of life, but at the same time certain influences, such as the parental attitude, may be present throughout, and therefore, as far as possible, the environmental factors considered in each group are the same as in the other groups with certain inevitable omissions and additions. In each case, a fixed scheme has been employed to tabulate the results of the enquiries; the scheme itself having no special characteristics, but is merely a personal variation of the type used in case records in many mental hospitals. At the end of each case thus dealt with, certain provisional conclusions, pertaining to the individual case, are noted for convenience in drawing up the collective result. The question of heredity in relation to mental disorder has already been referred to, and in a study of environmental factors as possible causative, or at any rate precipitating agencies in the breakdown of mental health, the influence of abnormality in the family stock is only considered where it might have a direct effect, in other words where continual contact with an abnormal personality might well be regarded as having an adverse effect on the individual's mental equilibrium. This attitude is, of course, in concordance with Janet's well known hypothesis. Recognising the contingency of damage to the unborn germplasm, the maternal health during pregnancy, the nature and duration of the labour and delivery, have been enquired into, and are grouped as "Eugenic" factors; but it was impossible to include a study of more distant events in the lives of the parents and earlier generations, which, according to some authors, e.g. Stockhard (5), are calculated to produce an indelible effect on the constitution of the offspring. After birth, the individual is almost inevitably exposed to psychic trauma, both in direct participation, or merely as a witness of distressing situations, to a variable degree depending on circumstances. Thus the extent to which an individual encounters adverse factors depends not only upon the adjustment which he or she is able to make to their environment, but also involves the reactions of other individuals who form an essential part of that environment. The latter component of the mental hygiene of the individual can well be expressed as the one word - "atmosphere ", and it is easily comprehensible how this psychic 'atmosphere" is certainly one of the most important factors, as it is rarely absent throughout the individual's life, being thrust upon him in the home, at school, and at work. The scheme used in this series of cases is accordingly designed to record both those classes of factors: the direct and the indirect, and is subdivided in order to distinguish those arising at home, in the school, at work, and in connection with various outside social activities. Furthermore, in each of the empirical age groups a brief description of the individual's personality, with special reference to any recognisable 'Schizoid" traits, is made. In this way the constitutional and environmental factors are tabulated side by side, to facilitate the examination of their possible interactions and relative importance in the production of. Schizophrenia. Together with the tentative results in each individual investigation, a short statement pertaining to the clinical features of the case is appended, and without resorting to any symbolic or analytical interpretations, mention is made of any obvious correlation between clinical and aetiological findings, and insight shown by the patient into the presumably adverse factors in the mental hygiene of his past existence.

THERAPEUTIC: To obtain the best results in prolonged narcosis, much depends upon the attitude of the patient towards the treatment and the environment in which he receives it. The less severe forms of mental illness benefit most from narcosis therapy, and the admission ward of a mental hospital is not the best place for the treatment of such cases. To overcome this difficulty, patients may be treated either in a "nerve unit" in the grounds of a mental hospital, or in a special ward of a general hospital. At this hospital a different arrangement has been used. A country house in pleasant surroundings about a mile from the mental hospital, has been converted into a nursing home which can accommodate twenty -five male and female patients. It is under the administration of the mental hospital and has a trained staff for nursing mentally ill patients. The stigma of a mental hospital does not exist, the patients are all voluntary and selected for their willingness and ability to co- operate in their treatment. Prolonged narcosis is best induced with sodium amytal and paraldehyde, while toxic complications may be minimised by the routine use of glucose and insulin with a high fluid intake. Narcosis therapy is a valuable therapeutic procedure if used in suitable cases, disappointing results will be obtained if it is used indiscriminately without regard to diagnosis. Cases that respond best are those of short duration, occurring in patients of good previous personality and precipitated by acute environmental. factors. Reactive depressions and anxiety states where the causation is largely exogenous do well. Prolonged narcosis restores the equilibrium in those cases of depression or overactivity, that are not too acutely ill. It may be likened to a rider on a laboratory balance, which by itself, can restore equilibrium when not too great an adjustment is necessary. Recurrent affective disorders either of mania or depression show improvement, the length of the illness being shortened. There is no evidence to suggest that the cyclothymic processes are affected, for recurrences will occur. The more severe depressions, where retardation is marked, may need a course of E.C.T. Involution depressions do not respond well and may become confused and hallucinated. If active measures of treatment are needed, E.C.T. will give good results in many cases. Early schizophrenics do not respond satisfactory to prolonged narcosis and should be treated with insulin coma as soon as possible. Chronic schizophrenics who are excited can be calmed down by narcosis therapy, but the disordered mental processes are not fundamentally altered. Patients, who are too agitated or overactive to benefit from psycho-therapy, can be restored by a course of prolonged narcosis to a more co- operative and receptive calm. ADMINISTRATIVE: Prolonged narcosis is a useful procedure for quietening and calming excited patients. In an admission ward such patients can he kept quiet and under control, and apart from the benefit to the patient, the ward remains orderly. New admissions are not frightened by noisy and excited patients when they enter the ward.

The History of the Treatment of General Paralysis of the Insane has been outlined - first the recognition of General Paralysis of the Insane as a clinical entity, and its relation to Syphilis, later the pyrexial treatment by malaria and other fevers, then chemo-therapy, and more recently electro-pyro-therapy. Accurate methods of Diagnosis of General Paralysis of the Insane (including the rare Juvenile form) are discussed. The Technique of Malaria Therapy is discussed, including the method of inoculation, the choice of the type of malaria, the selection of suitable cases, precautions during the course of the fever and the risks entailed. A brief outline of the Treatment of General Paralysis of the Insane by anti-syphilitic drugs is given,; but combined treatment with Tryparsamide and Bismuth is preferred. REVIEW OF CASES PERSONALLY OBSERVED: 180 Cases of General Paralysis of the Insane have been treated in Edinburgh from 1925 - 1938. Records of these cases have been perused. 80 Cases have been observed by the writer over an adequate period of time. The procedure adopted was a combination of Malaria Treatment and Tryparsamide and Bismuth Therapy. The results of treatment of 80 Personal Cases are discussed: 40.8% are reported as cured; 26.3%" " " improved; 14.5% " " " stationary; 5.3% " " " worse; 12.5% " " " dead. A standard is described by which the cases are judged. The Serological and Cerebrospinal Fluid changes after treatment are reviewed and the results are correlated to the clinical findings.

Prior to the introduction of streptomycin a few years ago, tuberculous meningitis was a one hundred percent fatal disease. It is now justifiable to present a thesis on the treatment of this disease for streptomycin is the first therapeutic agent to be used extensively and successfully in the treatment of tuberculous meningitis. That fifty percent of the patients now live is a remarkable advance, but the fact that half the patients succumb serves to show that treatment is powerless to save those in whom the pathological changes are severe and . incompatible with recovery. Thus death is sometimes inevitable if the disease process is already advanced beyond the limits of the therapeutic power of streptomycin. The only certain preventative measure is earlier diagnosis of the disease. sobering feature of the conquest of this disease is that, though many may now live, some are unable to follow a full and happy life for treatment is not without its complications, some of which are permanent and disabling. It is the purpose of this thesis to describe the results of treatment of twenty -six cases of tuberculous meningitis in all stages and to present some of the factors which make this treatment unsuccessful or unsatisfactory. The twenty-six cases to be studied in this thesis were admitted to Southfield SanatoriulL, Edinburgh between October 1948 and July 1951. The author has personally carried out the treatment of nine cases admitted after iiarch 195C and of five cases admitted prior to ìiarch 1950 but requiring treatment for varying periods thereafter. He has also been responsible for the follo1. -up and aftercare of all surviving patients including three in whom treatment was completed before 'kíarch 1950. The author was not_esponsible for the treatment of the remaining nine cases, all of whom were treated and died before _arch 1150. i em grateful to Professor Charles Cameron, i'iedical Superintendent, Southfield Sanatorium, Edinburgh, for permission to use the records of these nine cases. 1. The treatment of twenty -six cases of tuberculous meningitis has been described. It was found that the age group 10 - 20 years had the highest survival rate. The prognosis is unfavourable in children under 3 years of age. 2. The symptomatology of onset of the disease has been described. 7 cases presented with features of miliary tuberculosis, subsequently developing meningitis, while 19 cases presented with features of meningitis from the onset. In the former group a diagnosis of meningitis in an early stage was possible, and its onset varied between 3 - 13 weeks after the diagnosis of miliary disease was made. This earlier diagnosis does not universally lead to better results for the prognosis is less satisfactory when meningitis co- exists with miliary disease. 3. The results of treatment of the 26 cases are that 14 (54%) are alive and 12 (46%) are dead. Of the 14 survivors, 3 have been observed over 2 years, 8 over 12 - 24 months, and 3 continue to receive treatment. The highest survival rate occurred among the middle cases rather than the early eases because in the latter miliary disease largely influenced the outcome. 4. The tubercle bacillus isolated was of the human strain in 23 cases, and of the bovine strain in 1 case. The organism disappears early from the cerebro-spinal fluid following the introduction of intrathecal streptomycin. 5. The high fluctuating white cell count of the C.S.F., seen during the intrathecal administration of streptomycin, is not due entirely to the irritant action of the drug, but is probably the response of tuberculous meninges and tuberculous exudate to intrathecal streptomycin. As the meningitis subsides, the pleocytosis diminishes. Streptomycin leads to an increase in the polymorph-lymphocyte ratio of the C.S.F. The cells of the C.S.F. ha-:e never been found to return to normal so long as intrathecal streptomycin is administered. Even after discontinuation , many months elapse before a return to normal occurs. 6. the differential white cell count in the cerebrospinal fluid was described in detail. More satisfactory films were obtained using methyl alcohol to fix the film. The addition of protein to the C.S.F. during the preparation of a film reduced the disintegration of cells, especially polymorphs. It was thought that this method raised the osmotic pressure of the C.S.F. sufficiently to prevent such disintegration. 7. The causes of red blood cells in the C.S.F. have been discussed. As a consequence of streptomycin treatment, their occurrence is frequent and they have been found in more than half the specimens examined. On two occasions a subarachnoid haemorrhage has occurred. A high red cell count is the predominant response of the meninges to intrathecal tuberculin. 8. The protein content of the C.S.F. follows the pattern of the cell changes during the treatment of meningitis. A return to normal never occurs until after intrathecal streptomycin is withheld and it has usually been the last constituent of the C.S.F. to return to normal. 9. The sugar content of the C.S.F. has been found to be the most valuable in the early diagnosis and assessment of progress of tuberculous meningitis. The sugar value was below 50 mg.% at the time of diagnosis of all cases of meningitis. Higher levels were usually found in the earlier diagnosis of meningitis made in cases with miliary tuberculosis. With a satisfactory response to treatment, the sugar level gradually and consistently rose. It has been found that to discontinue treatment in a patient without symptoms and without clinical evidence of meningitis but with a C.S.F. sugar value below 50 mg.% leaves him in grave danger of a recrudescence of the disease. The estimation of the sugar content of the C.S.F. at variable periods after the fluid has been withdrawn has been discussed. It was found that the fall in the value depended upon the leucocytosis of the C.S.F. present. An insignificant fall occurred 48 hours after the withdrawal of the fluid if the cell count was normal. The addition of sodium fluoride to the specimen enabled dependable results to be obtained in the presence of a leucocytosis. 10. It was found that the chloride content of the C.S.F. was not of reliable diagnostic or prognostic significance.