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the patient is free of catatonia and associated symptom-complex (sympatheticotonia), but is still dull, apathetic and withdrawn; he often recalls events from the reactive phase, but without insight.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.

There have been several deaths during or after penicillin therapy for G.P.I. (Goldman, 1945; Neymann et al., 1945; Weickhardt, 1946, and Rose and Solomon, 1947), but there have been no reports of neuropathological studies. We think, therefore, that it may be of some value to describe the pathological findings in the brains of four such cases.

In recent discussions of the subject by Curran and Mallinson (1) and by Kinberg (2), emphasis has very properly been laid on the inextricable confusion that at present prevails in the use of the term “Psychopathic Personality.” Very many attempts have been made, for instance by Henderson, Cleckley, Cheney, Levine, Bullard and others (1), to characterize a syndrome. The characteristics of the syndrome have been seen in the make-up of the personality and its social relationships. But every authority disagrees with every other, and if there is any feature in common in all the definitions that have been provided, it is a lasting, but otherwise unspecified, incapacity to build up satisfactory social relationships. The confusion has gone so far that Kinberg has suggested that the term should be dropped altogether, particularly as it promotes a fatalistic attitude in the clinician and does not dispose to enthusiasm in therapy.

We are met to consider the application of psychoanalytical principles to hospital in-patients. Before we consider the applications it would be well to consider briefly, and have some agreement on, what those principles are.

The therapeutic factors operative in group treatment are still partially controversial, and further investigations are necessary to clarify their nature, mode of action, and range of curative potency.

This paper has been written with the intention of illustrating the application of psychoanalytic principles to the treatment of in-patient psychotics by reporting the treatment of a female manic-depressive patient by psychoanalysis at the Cassel Hospital during 1936–38. Unfortunately no reports of intensive in-patient psychotherapy of psychoses in this country have been published. Little prolonged intensive psychotherapy of psychoses has been carried out in hospitals, apart from the Cassel Hospital, where for many years the staff was sufficiently numerous to allow most patients to have daily interviews of significant length. In the United States experimentation has been much more active. Recently Fromm-Reichmann (1947) has reviewed many of the problems encountered in the several Mental Hospitals where psychoanalytic methods of treatment are actively pursued. Rosen has reported daring and courageous experiments. He has reported (1946) the treatment of acute catatonic excitements by psychoanalysis—his chief innovation being the long interview. With one patient the first interview was 16 hours with a break of half an hour. He has reported (1947) favourable results from treating 38 male and female schizophrenic patients, the ages of the patients ranging from 15–49, the duration of illness before treatment ranging from 1 month to 27 years, and the duration of hospital residence ranging up to 11 years. The average daily hours of treatment ranged from 1 to 12, and the duration of treatment ranged from 3 days to 11 months. In my opinion the New York Psychiatric Institute which encouraged Rosen's experiments has fostered a technique about which much more will be heard.

Once it has been established that a child has, in fact, committed the offence with which he has been charged, the interest of a present-day juvenile court is centred not so much on the nature of the offence itself as on the nature of the child and of the influences which may have contributed to the unconventional or antisocial attitude of which his offence may be the outward and visible sign.

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.

The pupils of a normal subject are generally described as equal, reacting by constriction or dilatation to various stimuli. Inequality of the pupils as an isolated finding is said to be relatively common, but impairment of the light reflex, especially in conjunction with pupillary inequality, is held to be strongly indicative, if not pathognomonic, of organic disease of the nervous system. An exception is the “tonic pupil,” for whose abnormally protracted reactions to light and accommodation an organic lesion has not yet been demonstrated. However, impairment of the light reflex is known to occur in subjects in whom there is no evidence of organic nervous disorder. These abnormalities of the light reflex have attracted little attention in this country, and are ignored almost entirely in text-books of neurology and psychiatry. Redlich (1908) made the important observation that muscular exertion might lead to dilatation of the pupil with impairment of the light reflex. Levine and Schilder (1942), in an extensive investigation of this phenomenon, concluded that muscular effort would produce dilatation and impairment of the light reflex in any pupil which initially retained its response to light, and would accentuate a pre-existing abnormality or bring out a latent tendency to impairment of the light reflex. Westphal (1907) first described the pupillary abnormality in catatonic schizophrenia to which the term “catatonic pupil” has been applied. This abnormality consists of pupillary dilatation with impairment of the light reflex, and is usually bilateral. The reactivity to light may vary from moment to moment, or from day to day; or pupillary rigidity may persist for a considerable time, with transient periods of brisk reactivity. Estimates of the frequency of the “catatonic pupil” vary remarkably—from 54 per cent. (Schilder and Parker, 1931) to 3.4 per cent. (Reichmann, 1913). Apparently a higher incidence has been found where repeated examinations have been carried out on the same subjects, but proper comparison is impossible, as the technique of examination has not been detailed by any of the authors.

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.

There is no need for re-stating, in general terms, the importance of the psychoanalytical contribution to psychiatry. This has been discussed here on several occasions, and possibly more seriously than in any other society of psychiatrists. I am referring to the papers read to this section by Bernard Hart (1), David Forsyth (2) and Edward Glover (3). They form a most interesting introduction into the problem of the relationship between psychiatry and psychoanalysis. Psychoanalysis has not been the main topic of discussion in this section since Edward Glover's address on the application of psychoanalytical principles in psychiatry thirteen years ago. Since then the psychiatric scene has changed out of recognition. We have entered an era of great therapeutic activity. The hospital in-patient with whom we are concerned to-day has been subjected to a variety of physical methods, and the campaign has still not reached its peak of intensity. It is too early, at this stage, finally to assess the therapeutic value of those treatments, but we can say this much already: it is most unlikely that they will save us the trouble of studying mental illness the hard way. Psychiatry cannot afford to neglect any approach that promises to contribute to the understanding of mental phenomena. It is against this background of psychiatric developments that psychoanalysis has again been chosen for discussion here.

I do not think that anyone, professional or layman, will contradict the statement that the family unit is, at least in our culture, the best medium for the growing child. Yet, although there is tacit recognition of this fact, it is only in recent years that more attention is being paid to providing for children, who in infancy are left without parents, with this most suitable environment for their development. In this and other countries there are still vast institutions, insufficiently staffed, entrusted with the task of bringing up hundreds of children who, we know, will become unsatisfactory citizens.

Although homicidal tendencies are well recognized in the depressive psychoses, this medico-legal aspect of the illness receives only cursory mention in text-books, e.g. Henderson and Gillespie and Noyes, if it is referred to at all. Inasmuch as it is on this most serious complication that the psychiatrist is most liable to be asked to give evidence in court, there would seem to be good reason for examining the factors leading to such behaviour, and comparing them with similar data from non-depressive homicides. It is hoped that these notes will show a behaviour complex peculiar to the melancholic subjects.

“No collection of facts is ever complete because the Universe is without bounds, and no synthesis or interpretation is ever final, because there are always fresh facts to be found after the first collection has been provisionally arranged.”

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.

The mental hospital of to-day has developed in stages from the earliest of which we have any particulars.

Progress in planning and design has been gradual, with periods during which it has been pronounced. Each period has shown an advance in the lay-out and detailed arrangement of the buildings to meet the coincident advance in methods of care and treatment of the patients.

Electronarcosis is a state of coma, or anaesthesia, induced and maintained by the continuous passage of electricity through the brain. Although described in animals and man many years previously, it was not introduced into psychiatry until 1944, when a group of Californian workers (Frostig et al.) experimented with its use as an alternative to insulin coma treatment in schizophrenia.

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

I welcome the opportunity of presenting this short paper to the meeting, particularly as I have just returned from the United States, where I have seen something of the modern trend of psychiatry in that country.

The memorandum on the future organization of the psychiatric services, published by this Association in 1944, defines a psychiatric unit as that part of a general hospital, whether in-patients or out-patient, which is set aside for the treatment of mental disorders, with or without legal formalities.

A Complex is a group of emotionally invested ideas that have unconscious activities. Contrary though it be to the popular and sentimental idea of an overriding mother love, it is common, especially in child psychiatry, to find a mother's lively hatred and even homicidal wishes towards her child. I consider that this should be called “The Medea Complex.”