SUMMARY Twelve patients with severe intractable epilepsy were treated by chronic cerebellar stimulation under double-blind conditions for six months. No reduction in seizure frequency occurred that could be attributed to stimulation, though eleven of the patients considered that the trial had helped them. One patient experienced fewer episodes of incontinence during stimulation. Cerebellar stimulation in its present form cannot be recommended for the treatment of severe intractable epilepsy.Therapeutic effects of cerebellar stimulation in severe epilepsy were first reported by Cooper.' A later report summarised the outcome in a total of 32 patients.2 Seizure frequency fell to half or less of the pre-operative rate in 18 patients and nine were regarded as therapeutic failures. One died at operation and four others died subsequently in their sleep. Two of these had not responded to stimulation, one had been free of grand mal and petit mal attacks for the six week period between implantation and death and the response of the fourth was not described. Treatment was uncontrolled and assessment open.Several other reports3-6 have since appeared which have supported the concept that cerebellar stimulation improves epilepsy, although the effect was less pronounced than in Cooper's series. Only one double-blind study7 has been performed. This involved five patients, of whom three, on the criteria recommended by Cooper et al,8 might not have been expected to respond favourably.Severe epilepsy has an appreciable morbidity. Mortality is also increased, especially in young adult males. Lennox9 quotes an overall death rate of 11-4 in the age group 25-45 compared with a rate of 3-1 in the general population. Therefore it is extremely important to establish whether or not this treatment should be recommended for occasional cases of severe intractable epilepsy. The present uncertainty

The first comprehensive in vivo documentation of the long term profile of pathological and spared tissue is described in a group of 10 patients with a diagnosis of herpes simplex encephalitis, who were left with memory difficulties as a major residual sequel of their condition. With a dedicated MRI protocol, which included high resolution images of temporal lobe and limbic system areas, data are provided on structures that have recently gained importance as anatomical substrates for amnesia. The major features of the lesion profile were: (1) unilateral or bilateral hippocampal damage never occurred in isolation, and was often accompanied by damage to the parahippocampus, the amygdala, specific temporal lobe gyri, and the temporal poles; (2) the insula was always abnormal; (3) neocortical temporal lobe damage was usually unilateral or asymmetric. It never occurred in isolation, and was invariably associated with more medial pathological changes; (4) anterior and inferior temporal lobe gyri were damaged more often and more severely than posterior and superior temporal lobe gyri; (5) pronounced abnormality was often present in the substantia innominata (region of the basal forebrain/anterior perforated substance); (6) there was evidence of significant abnormality in the fornix; (7) there was evidence of damage to the mammillary bodies; (8) thalamic nuclei were affected in around 50% of cases, with damage usually unilateral; (9) frontal lobe damage was present in a few patients, and affected medial areas more than dorsolateral areas; (10) there was some involvement of the striatum, although this was usually unilateral and mild; (11)

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Mental Illness-Shepherd et al. MEDBCAL JOURNAL 1363 and for the detection of causal associations among these complex conditions. At the same time the study underlines the need to extend and refine available techniques of measurement. Even with carefully defined criteria of illness the wide variation between practitioners' prevalence rates points to two potent groups of factors. The first of these relates to the ecological differences between practices and can be offset by paying regard to the size and representativeness of the sample of participating doctors. The second relates to the doctor, his attitudes, and his interactions with his patients ; for psychiatric illness, as we have shown, they constitute a major source of variation. SummaryThis paper reports on a general practice survey of psychiatric morbidity carried out in the Greater London area. The sickness experience of nearly 15,000 patients on the lists of 80 practitioners was studied over a period of one year. It was shown that minor psychiatric disorders, classified according to a predetermined schema, were diagnosed in 14% of the population at risk. Neurotic illness was most prevalent among middle-aged females and proved to be an important cause of chronic illness. The reasons for interpractice variation in recorded morbidity are discussed.We are grateful to the following general practitioners, whose cooperation made this study possible. (1957, 1961) found a high incidence in a post-mortem series of patients who had had a cerebrovascular accident, but they did not study any control subjects; they suggested that extracranial arterial disease was a common cause of cerebral infarction through its direct effect on cerebral blood flow. Schwartz and Mitchell (1961) showed that atherosclerosis of these arteries, as with atherosclerosis elsewhere, correlated well with age, that it was common even in patients without cerebrovascular accidents, and that a correlation between cerebral infarction and extracranial atherosclerosis could be due largely to the fact that both were correlated with age. The occlusive lesions described by these authors varied from small plaques scarcely narrowing the arterial lumen to complete occlusion of one or more of the extracranial arteries. The incomplete lesions were classified, according to the percentage reduction of the normal lumen, into mild or moderate (less than 50% reduction) or severe (more than 50% reduction); no evidence is available to assess the possible effects of such stenosis on cerebral blood flow.Alteration of calibre may be of importance either directly, by its effect on cerebrovascular resistance, or indirectly, producing turbulent conditions of flow which might predispose to local platelet aggregation. In this paper we are concerned with the effect of narrowing of carotid arteries on their hydraulic resistance only, and report experiments designed to determine the approximate dimensions and hydraulic resistance of the minimum narrowing which has a detectable effect on blood flow through the artery. We...

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