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million doses of gamma-globulin will be available formass inoculations this year, compared with one millionlast year; and an unusual position may conceivablyarise in which the supply of gamma-globulin exceedsthe demand. In view of these developments, the vac-cination trial 4 which the National Foundation is carryingout this year becomes more important than ever.

Approximately 500,000 children are being vaccinatedwith an inactivated tissue-culture vaccine to see whetherit will protect them against paralytic poliomyelitis.

4. See Lancet, 1953, ii, 872.5. January, 1954, p. 10.6. See Lancet, 1952, i, 651, 664.

THE MENTAL HEALTH RESEARCH FUND

MENTAL health has seldom been a warmly favouredchild of those who disburse research grants ; andthe demands on the Mental Health Research Fund,founded in 1949, are likely to be great and growingfor many years to come. What it has done already,and what it hopes to do, are set out in the current issueof the Journal of Mental, Science.5Careful thought has been given to the lines on which

it should develop. A conference held at Oxford inthe spring of 1952,6 to which were invited scientists fromall branches of research bearing on mind and brain,provided " a clear though complex picture " of whatis going on in territory which extends from the anatomyof the nervous system and the biochemical and electricalactivities of the brain on one hand to the work of thechild-guidance clinic, the mental hospital, and the specialschool on the other. The fund takes all this for its

province, its objects being :"To promote, finance, and encourage research on mental

health and disease, notably : (a) study of the factors c’on-ducive to the fullest development and maintenance of man’smental capacity ; (b) research on the causation, preventionand cure of nervous and mental illness ; (c) research onfundamental problems related to mental health, such as thephysiology of the nervous system ; (d) research on the forms ofsocial structure most likely to lead to the improvement of themental quality and stamina of the community and most likelyto reduce the incidence of addiction, delinquency and crime."Some of the ground has been further explored. The

Oxford conference led to one on the psychological develop-ment of the child, convened by the World Health

Organisation at Geneva- in 1953 ; and this was followed

by another on the same subject two months ago. A

meeting, in Bristol, of biochemists and others who hadattended the Oxford conference resulted in plans for asymposium on the development of the nervous system,to be held at Oxford next July ; and this will be organisedand sponsored by the fund. Then, research projectsare to be fostered by one or more fellowships carryingsalaries of nOOO-1500, and applications are soon to beinvited for the first of these, the only stipulation beingthat the applicant must be willing to undertake workwhich has some bearing on mental health.The fund has decided on some general rules as to the

ways in which it can best use its resources. As occasionoffers, it will finance conferences between research-workers-either small groups approaching a single topicfrom different aspects, or larger groups with a biggerrange. It will also make travel and subsistence grantsto workers who wish to confer with colleagues of similarinterests, to visit a different laboratory to learn a newtechnique, or take part in joint research at some othercentre. It will foster the projects of individuals eitherby means of fellowships, or by adding something to anexisting salary so as to enable the worker to continue,indefinitely or for a limited time, in research, or bypaying an alternative person so as to release the workerfrom part of his duties, or by means of grants for equip-ment and technical help. Prizes and awards will begiven, at two-yearly or other regular intervals, and these

will include awards, given without previous notification,to young research-workers, for advances which bearon mental health. The fund will also support efforts

(either its own or those of any other approved body)to raise the amount of public or other research fundsallocated to mental-health research : it will, for instance,advocate that the number of research professorships anddirectorships of clinical research in mental hospitals beincreased, and that the conditions of service of research-workers should be improved, and interest in this fieldstimulated. Finally, it will support any other projectbearing on mental health which does not fall into anyof the classes enumerated, but which the research com-mittee consider deserves approval. This committeewill also have the task of selecting projects to be givenfinancial help. It will base its decisions on the abilityof the man who is to undertake the work, on the situationin mental-health research at the time of his request,on the extent to which funds may be had from othersources, and on whether the men and material seemsufficient to get decisive results. Generally the preferencewill be given, as mentioned already, to projects whichcan be attacked in cooperation by workers trained indifferent disciplines and having different skills.

This programme, which is in the best tradition of

English grant-giving bodies, has a warmth and energyabout it appropriate to the spring season in which it isgrowing : it should set the sap rising in mental-healthresearch.

1. Gold, S. C., Gowing, N. F. C. Quart. J. Med. 1953, 22, 457.2. Rapaport, S. I., Meister, L., Steele, F. M., Caniglia, S. R.

Ann. rheum. Dis. 1953, 12, 268.3. Callender, S. T., Race, R. R., Paykoç, Z. V. Brit. med. J.

1945, ii, 83.

SYSTEMIC LUPUS ERYTHEMATOSUSCOLLAGEN disease is now fashionable, so it is liable to

be diagnosed whenever the signs and symptoms do notseem to fit together. Certainly the clinical picture ofsystemic lupus erythematosus is bizarre enough. Goldand Gowing note that this disorder occurs almostexclusively in young women between the ages of 20 and40. As regards the skin lesions, chronic discoid lupuserythematosus may progress sometimes to the systemicvariety ; in addition there may be

" a wide variety of

rashes occurring simultaneously or in succession."Purpura of thrombocytopenic type may be the presentingsign. Arthritic symptoms are prominent ; and usuallythey are relatively acute. The muscles may be swollenand tender, as in dermatomyositis. Renal symptomsare uncommon ; but progressive renal involvement, whenit does occur, is always a bad prognostic sign. Diarrhoeais often troublesome, and various other gastro-intestinalsymptoms have been recorded. Pleural effusion is

frequent and, when accompanied by pericardial effusionand ascites, may be wrongly ascribed to

" polyserositis."Widespread enlargement of lymph-glands is common,splenomegaly less so. Sometimes focal vascular lesionsin the central nervous system give rise to signs. This listis not exhaustive ; for instance, Rapaport et a1.2 havelately described 2 patients with presenting signs andsymptoms in the lungs.

In diagnosis clinical pathology gives much-needed help.The most important biochemical change, according toGold and Gowing, is hyperglobulinaemia; and " thediagnosis should be suspect if this is absent." This

hyperglobulinsemia is reflected in abnormal results ofother tests-for instance, increased erythrocyte-sedi-mentation rate (E.s.R.) and an occasional false positiveWassermann or Kahn reaction. The Coombs anti-

globulin reaction for red cells may also be positive : Goldand Gowing had 8 positives in their 26 cases. Further-more multiple antibodies may be formed after blood-transfusion ; for example, in a case described by Callenderet al.3 5 separate antibodies developed after multipletransfusions. Routine blood examination shows no

560

diagnostic points, except perhaps leucopenia and relativemonocytosis.4 The presence of

" L.E. cells " in the blood 5

confirms the diagnosis, but their absence does notexclude it. Gold and Gowing found such cells in only6 out of 15 patients tested ; but other workers havefound them in a much higher proportion of cases.6

Possibly the L.E.-cell phenomenon is not as specific ashas been thought ; it may be another sign of disturbedantibody mechanisms. Barbier has obtained a positiveL.E.-cell test in a patient with allergic skin reactions afteradministration of penicillin and sulphonamides, and henotes that 15 similar cases have been recorded. Theurine commonly contains both red and white blood-cellsand sometimes hyaline or waxy casts; albuminuria mayor may not be found.

Of the many morbid-anatomical changes that whichhas attracted most attention is fibrinoid degenerationof collagen-fibres. This degeneration, which is also a

feature of other collagen diseases, is followed by hyalinisa-tion and sclerosis. In addition there may be true fibro-blastic proliferation, necrosis of connective-tissue cells,and inflammatory (usually " round-cell ") infiltration ofthe degenerate or necrotic tissues. In clinically typicalcases, however, the changes found at necropsy may bevery slight.The aetiology of lupus erythematosus is quite unknown.

Baehr and his co-workers in the U.S.A. have regardedchronic discoid lupus and systemic lupus erythematosusas clinically distinct conditions ; but lately the opinionthat the two conditions are stages of the same diseasehas been gaining support. Sir Henry Cohen and Dr.Cadman 8 have reported a series of cases showing transi-tion stages from the chronic discoid form, without thebiochemical changes of systemic lupus erythematosus,to the acute systemic form with typical changes. Goldand Gowing are convinced that the two conditions areintimately related, especially as careful investigation ofcases of the chronic discoid type often reveals biochemicalchanges found in the systemic type, such as hyper-globulinaemia or raised E.S.R. But although it seems thatthe discoid form does sometimes develop into the systemic,most cases of systemic lupus erythematosus have notpassed through a discoid stage. Both conditions showfeatures of hypersensitivity states, and in systemic lupusthere is evidence of gross disturbance of antibodyreactions and formation. The factor that produces theL.E.-cell phenomenon is now known to be a gamma-globulin that differs immunologically from normal gamma-globulin. 9 Recently Bridge and Foley 10 have describedthe transmission across the placenta of the L.E. factor.A patient with systemic lupus erythematosus controlledby regular cortisone treatment was delivered of a full-term child ; the baby’s blood at first gave a positiveL.E.-cell test, but 7 weeks after birth the effect could

hardly be detected and at 4 months the test was quitenegative ; the mother’s blood continued to give a

positive test. Lupus erythematosus may well fit intothe group of conditions named by Ehrich 11 the " dys-gammaglobuhn2l,-mias." Such a grouping explains theobservation that all " specific " tests and reactions forlupus erythematosus can be positive in other relateddiseases ; as in so many other diseases, it is the totalclinical and pathological picture that leads to a properdiagnosis.

Interest in systemic lupus and its accurate diagnosishas been stimulated by reports that the disease may besuccessfully controlled by cortisone or corticotrophin.Most of these reports come from the U.S.A., but Cohenand Cadman in this country have reported good results4. Stickney, J. M. Proc. Mayo Clin. 1940, 15, 680.5. See Lancet, 1951, ii, 110.6. Zimmer, F. E., Hargraves, M. M. Proc. Mayo Clin. 1952,

27, 424. 7. Barbier, F. Acta med. scand. 1953, 147, 325.8. Cohen, H., Cadman, E. F. B. Lancet, 1953, ii, 305.9. Haserick, J. R., Lewis, L. A. Blood, 1950, 5, 718.

10. Bridge, R. G., Foley, F. E. Amer. J. med. Sci. 1954, 227, 1.11. Ehrich, W. E. Amer. Heart J. 1952, 43, 121.

in 5 cases of acute systemic lupus erythematosus withcorticotrophin and cortisone. They note that fever,anorexia, and malaise remitted within a few hours afterthe start of treatment, joint pains and the rash within aweek, and lymphadenopathy and splenomegaly within3 weeks. Cohen and Cadman gave maintenance treatmentwith oral cortisone in doses varying from 37-5 mg. to75 mg. daily for 8-30 months without relapse; but, likeothers, they found that the L.E.-cell phenomenon persisted-it became negative only in 1 case. They agree withDubois et al.12 that mild cases should be given a chanceof spontaneous remission, which cortisone treatment mayinhibit. Treatment with these hormones is not alwayssatisfactory, and other methods have been tried. Rohnand Bond 13 used nitrogen mustard and triethylenemel.amine in relatively small doses, and claim to have inducedremissions varying from 6 to 217 days in 7 patients-results that compare favourably with those from corti.sone. The mode of action of these drugs is far fromclear, but if systemic lupus erythematosus is in fact anantibody disturbance there is some ground for usingcortisone or corticotrophin. Until we have a betterremedy patients should be given the benefit of a trialwith these substances.

12. Dubois, E. L., Commons, R. R, Starr, P., Stein, C. S., Morrison,R. J. Amer. med. Ass. 1952, 149, 995.

13. Rohn, R. J., Bond, W. H. Amer. J. med. Sci. 1953, 226, 179.14. Abse, D W. Quart. Rev. Psychiat. Neurol., Int. Rec. Med. 1958.

166, 287 ; J. ment. Sci. 1940, 86, 95 ; Brit. J. med. Psychol.1942, 19, 262 ; Ibid, 1944, 20, 33 ; Ibid. 1949, 22, 194.

15. Freud, S. Collected Papers. London, 1924; vol. 1, chapter 2.

SHOCK TREATMENT AND PSYCHE

ALTHOUGH widely practised in modern psychiatry,shock treatment-whether by electroconvulsive therapy,convulsant drugs, or insulin coma-is apt to be left tothose psychiatrists who are less interested than othersin psychotherapy. The views of Abse 14 are based onlong experience both of psychotherapy and of shockmethods.Abse considers that the essence of all forms of shock

treatment is the traumatic situation in which the patientis placed. This causes physiological changes, which arenormally reversible, and also psychic effects, which areirreversible even when produced during unconsciousness.In support of this belief, he instances not only the

patient’s overt anxiety about the treatment or its

preliminaries, but the revelation during concomitant orsubsequent psychotherapy of fantasies concerned withdeath and destruction, of being raped or overwhelmed,or of undergoing dangerous and terrifying experiences.These fantasies, he says, derive not only from thecircumstances of the treatment but from the activationof pre-existent unconscious fantasies; and he cit6Freud’s 15 dictum that events occurring in the absence ofconsciousness may produce powerful intrapsychic effects.The repeatedly induced traumatic situation may bring

about two beneficial types of response-improved contactwith reality, and relief of depression. The first of theseAbse attributes to the anxiety evoked by the traumaticsituation stimulating the ego’s defences and enabling itto repress id impulses more effectively : in this thera-peutic process he sees an analogy to the normal develop-ment of reality-testing in the infant, according to theorthodox psycho-analytical theory by which the iafantego is driven by anxiety to repress some of its instinctualimpulses and to turn to the outside world to seek need-satisfying objects for the remainder. Shock methods,he points out, may stimulate other types of ego defences,and where these take the form of regressive or projectivemechanisms the treatment may be ineffective or actuallyharmful. The second main therapeutic effect-the reliefof depression-he believes to be due to the relief oftension between ego and superego consequent on theunconscious experiencing of a situation equivalent to

punishment. Normally the ego represses id impulses atthe behest of the superego, but where this function M