Symptoms attributed to dysfunction of the ductless glands have long been noticed in the group of mental disorders formerly known as dementia praecox, now included in the wider designation schizophrenia. A variety of such abnormalities has been described, but without sufficient consistency or clarity to help in formulating a pathology of the disorder. From the first, the usual onset in adolescence or early adulthood, and the symptomatology, prompted investigation of the gonads. Papers have been published by Fränkel (1919), Mott (1919), Pézard (1920), Tiffany (1921), Lewis (1923), Morse (1923), Geller (1923), Münzer (1926), McCartney (1929), in which histological changes in the testis in schizophrenia are cited and discussed. The contributions of Mott, Lewis and Morse are the most important, for their material and histology are more accurately controlled and described. It appeared as if the very extensive work done by Mott had succeeded in establishing a direct relationship between gonadal failure and dementia praecox. Subsequently his findings were heavily criticised and the conclusions to a great extent rejected, for, like others, he had obtained material at post mortem, mostly from patients who had died of tuberculosis or other diseases liable to produce the very changes he regarded as specific; very few were young adults in the early phases of the mental disease. These objections constituted an apparently insuperable difficulty, and the whole question has remained virtually in abeyance ever since.

In another paper in collaboration with Reiss and Taylor (1944) I have described and classified the state of testis function in schizophrenia, mental defect, and the common mental illnesses from an examination of specimens obtained by biopsy from 115 representative subjects, selected for adequate physical health and development. It was found convenient to classify all material in five grades according to the histological appearances. These have been fully described in our paper. In brief they indicate (1) complete normality, (2) normality with slight defects, (3) moderate atrophy, (4, 5) severe and very severe atrophy amounting in the worst cases to total loss of normal function. While we have regarded a Grade 3 specimen as significant in young subjects, it is probably not necessarily outside the normal expectation from the fourth decade upwards. Grades 4, 5 are, of course, indicative of a severe atrophying process at any age. In analysing the defects we noted and described degeneration of the seminiferous elements with changes in the tubular capsule. The basement membrane was affected first and principally, and underwent a form of hyaline degeneration. This, we felt, was the underlying cause of the atrophy of the seminiferous epithelium, and eventually led in many instances to complete destruction of lengths of the affected tubules. The interstitium was not subject to important change.

About 15–20 per cent. of cases of head injury of moderate or severe degree are followed by persisting intellectual impairment, causing loss of efficiency often increased by psychoneurotic symptoms arising from such incapacity. Deterioration of powers of sustained attention, of recent memory and of emotional control are characteristic of post-traumatic states after severe head injury, but ignorance of the patient's previous capacity and personality makes it difficult to assess psychological and physical factors—to distinguish between the patient who is ineffective because he is neurotic and the one who is neurotic because he is ineffective—as a result of cerebral damage. Therefore any reliable index of damage to the “matrix of the mind” will be helpful in prognosis and in deciding disposal.

In a previous article (1) the writer gave the results of a scale of 25 mental tests on a group of 20 senile patients. When that investigation was completed the scale was administered to a second group of seniles (Group b), who were considered to be in a more advanced state of dementia than the first group.

Although by now many papers have been published on psychiatric cases occurring in the Forces in this war, few follow-up studies are available of cases discharged to civilian life. Lewis (1943) and Ferguson (1943) found that a considerable proportion of discharged psychiatric patients had required further medical treatment and had difficulty in resettling to work.

The careful contribution on “Prisoner-of-War Mentality” by Major P. H. Newman (Brit. Med. J., vol. i, p. 8, 1944) has provoked this record of related psychological reactions. The men and women to be described, though not prisoners-of-war, were nevertheless imprisoned by psychological difficulties no less harassing than those material restraints, which, as Newman points out, operate mainly by frustrating or reducing to futility the accustomed interests, satisfactions and tasks of human beings. In the problems of prisoners-of-war a large part is played by retreat into phantasy. It is suggested below that, in human affairs and in clinical work, the scope of this particular reaction to frustration is very much wider than is commonly realized. The range is probably from what is colloquially called “uplift,” to mental states not very unlike psychoses (which have in fact been referred to as “pseudo-psychoses”), and, indeed, possibly to the psychoses themselves.

“No man will be a sailor who has the contrivance enough to get himself into a jail, for being in a ship is being in a jail, with the chance of being drowned.”—Dr Johnson (1759).

In recent years important additions to the knowledge of the symptomatology in cases with involvement of the parietal lobe have been made. Both constructional apraxia (Kleist, 1922) and Gerstmann's syndrome, consisting of finger-agnosia, disturbance of right-left orientation, agraphia and acalculia (1924) have been related to lesions of the angular gyrus of the dominant hemisphere. Before the description of those symptoms, a loss of spatial orientation had been described in cases with lesions of the same localization. Balint (1910), Riddoch (1917), and others had observed that symptom in single cases, but the most comprehensive description was given by Gordon Holmes (1918), who studied it in a case-material of war injuries. When Holmes and his co-workers published their observations, constructional apraxia and Gerstmann's syndrome were still unknown. Loss of spatial orientation as a fully developed symptom is rare, while the other two disorders are not uncommon. For this reason the psychopathological relationship of those symptoms is still insufficiently understood. The following case offers an opportunity for studying the problem:

This condition, in which severe confusion, disorientation, and restlessness are the principal features, appears to have been first clearly described by Bell (1845), who noted that about 2½ per cent. of the patients admitted to his asylum showed a particular syndrome: they were normal people who were admitted after about a week's acute illness; their appearance and speech suggested fever and delirium like a typhoid state; understanding was limited; they were apprehensive, with distressing but confused delusions; they disliked and suspected their food, and were not sensible enough to be thirsty; they tried to get out of bed, were sometimes violent, and struggled strongly when held. The course of the illness was rapidly downhill, but about a quarter of the patients suddenly made a complete and permanent recovery at the end of two to three weeks, the remainder dying in the same time. There were no specific post-mortem findings.

In recent years the scope of various physical psychiatric treatments has been defined more clearly. Broadly speaking, continuous sleep for acute and subacute anxiety reactions, electro-convulsive treatment for depressions, insulin comas for schizophrenia with or without fits, malaria for G.P.I., and so on. In 1941 my colleagues, Drs. Sargant and Craske, described a modification of insulin shock therapy for treatment of war neuroses in the Services. In 1944 we find the method maintaining its effectiveness, its indications more definite, its scope widened through trial in various psychiatric states, and checked by control experiments. From the 850 odd patients so treated at Sutton I have selected some 320 as the basis of this paper, whose courses of insulin I have given personally. The great majority of this number are civilians, and the forms of their illnesses do not differ materially from those familiar in peace time. In properly chosen cases the results are as satisfactory as with Service personnel. The treatment is free from the potential dangers of other physical methods.

Depression or dysphoria in its various forms is probably the commonest single symptom encountered in military psychiatry, and its differential diagnosis is often a matter of extreme difficulty: The author's observations, based on three years' experience as psychiatrist in a military psychiatric hospital, have shown that of a large number of cases admitted with a diagnosis of “depressive psychosis,” by far the greater proportion are not psychotic at all, but are cases of an acute reactive neurotic disturbance, characterized by a variety of mixed anxiety, hysterical and psychopathic features, and combined with a marked disturbance in the sphere of affect and personality.

Levy et al. (1942) reported impaired memory in 8 out of 11 patients treated by electric shock. Impairment lasted from one to several weeks, and in one patient was present after several months. Grinker, discussing this paper, compared the psychometric and clinical picture following electro-therapy with that seen in the “punch drunk” syndrome, in which careful testing, he warned, reveals permanent damage. This to my best knowledge is the only note hitherto made that impairment of memory occurring during or after electro-therapy has any serious significance. The following case-notes revealing memory defects lasting a year or more suggest that Grinker's apprehensions may be justified.

Since its inception, shock therapy has become rather more restricted in its field of application. During the initial phase of enthusiasm and trial it was used freely in all the functional psychoses, but now many observers are agreed that its main usefulness lies in the group of depressive reactions and the melancholias. The results in the schizophrenic group are generally disappointing. In reviewing a large series of shock-treated cases, Penrose (1) reports 1.4 per cent: more treated schizophrenics in hospital than expected in comparison with a control group.

Cases of unilateral hydrocephalus not due to obstruction of the foramen of Monro are rare, and not more than a dozen accounts of such cases have been published. The Journal of Mental Science of July, 1940 (pp. 591–601), contains a paper by R. M. Stewart which gives an excellent review of cases previously published, including two cases of his own.