A hundred years ago it was generally believed by the medical profession, and particularly by alienists, that masturbation was an important and frequent cause of mental disorder. Today no one believes this; and the masturbatory hypothesis (as we may call it) has in all probability been finally abandoned. If we enquire into the history of this change we find, somewhat surprisingly, that medical references to the harmfulness of masturbation are vanishingly rare before the 18th century. For practical purposes, the whole history of the masturbatory hypothesis is contained within the last 250 years. This history is not one in which the present-day psychiatrist is apt to feel much pride. Yet it is worth studying, not only for its own sake (and the history of psychiatric ideas is a much neglected subject), but also for the light it throws on the peculiar difficulty of refuting causal hypotheses in psychiatry. The aim of the present essay is, first, to give a short history of the idea that masturbation is an important cause of mental disorder and, second, to examine some of the reasons for the rise and fall of this idea and why it persisted for so long (1).

There have been abundant studies of dreams from the point of view of their content, but few have examined the mode of dreams irrespective of content. For analysing and interpreting the content of dreams first-hand accounts have been used, but these verbalizations—owing to communication limitations alone—are far from identical with the dream experience. These verbalizations necessarily lump together the elements of the experience in order to provide a coherent description.

Recent improvements in the treatment of psychotic patients (Ministry of Health, 1960; Registrar General 1957 and 1958) have, by contrast, drawn attention to the non-psychotic population of mental hospitals. This paper deals with this latter group. Their self-referent attitudes have been chosen for study as there is a persistent tradition in psychology which asserts their importance. This can be traced through McDougall (1923), the writings of Jung on Individuation (1939), Hilgard (1954), Sherif and Cantril (1947), Symonds (1951) and Carl Rogers (1951). Associated with this tradition is the concept that an important change in the attitude of a person to himself may lead to important changes in behaviour. This, if true, holds out hopes of therapeutic advance. This paper therefore studies the self-referent attitudes found in a characteristic sample population of non-psychotic patients in mental hospitals.

Headache alone is estimated to be the chief and central complaint of eight million people (8). In one series of five hundred cases only ninety-six were found to have an organic basis (4).

Owing to the use of other therapeutic measures in mental hospitals, interest in brain operations undertaken for the relief of psychotic symptoms has fallen to a minimum. Hence, opportunities for studying the mental effects of such cerebral lesions are now practically non-existent. The investigation by Aaron Smith (1960) of the residual deficits as shown by the Porteus Maze Test in cases who had suffered topectomies eight years previously, as reported in this Journal in July, 1960, may very well be the last word on the subject. The time seems opportune, therefore, to make a brief summary of the results of a test that is now considered to be the most sensitive to frontal brain damage.

The statistics on mental hospitals published by the Ministry of Health (1957) show that the average length of stay for admissions to mental hospitals decreased in the period 1952–1956. According to the Registrar-General's Mental Health Supplement (1961) there was an average saving, between 1951 and 1958, of sixteen days for men and thirteen days for women, among patients staying less than one year. But these figures for stay only relate to the patients discharged each year, irrespective of the year of their admission, and furthermore we do not know what happens to particular groups such, for example, as schizophrenics. Although remarkable changes are occurring at the present time, study of them is hampered by lack of appropriate and up-to-date information.

Advances in hospital care of the elderly have led to an urgent demand on these services, and Cosin (2) has pointed out that it has often been necessary to provide them before their most practical uses have been evaluated. As Townsend (11) observes, some beds are occupied by patients who should have been in a different hospital unit more fitting to their particular type of disability.

In recent years an ever-increasing interest has been taken in the possible use of serum enzyme investigations in clinical diagnosis, prognosis and therapy control. That clinical abnormalities are accompanied or even induced by biochemical aberrations is accepted. That the serum enzyme pattern may show consequent abnormality before the signs and symptoms familiar to the physician appear, has been also demonstrated in several disease states, such as caeruloplasmin in Wilson's disease (Scheinberg and Gitlin, 1952) and the transaminases in infective hepatitis (Wroblewski, 1957).

The fasting blood acetyl methyl carbinol (A.M.C.) level was shown to be high at the start of the depressive phase in manic-depressives by Dawson, Hullen and Crockett (1). Such cases also showed large fluctuations of fasting blood A.M.C. level compared with normals. The findings in a manic-depressive patient investigated more recently are shown in Figure 1; those in a normal female are given also for comparison. In the manic-depressive, it can be seen that the fasting blood A.M.C. level tended to fluctuate widely, to be high before and at the start of a depressive phase. There is no evidence to suggest that A.M.C. in the quantities found could cause psychiatric manifestations (Stotz, Westerfeld and Berg, 8). It is hence possible that the alterations in A.M.C. level were merely an indication of an abnormal variability of some part of the biochemical milieu. It was decided therefore to investigate patients with other forms of depressive illness to see whether or not abnormalities of A.M.C. level and variability were present, similar to those in manic-depressives.

Patients in the care of the Department of Psychological Medicine, Guy's Hospital, who are receiving moderate and large doses of phenothiazine drugs are regularly tested for evidence of hepatic or haematological disturbance. In the course of such an investigation, when the urine of a schizophrenic patient was tested with modified Ehrlich's reagent for urobilinogen, it was remarked that a deep blue colour was produced. The patient had been receiving 600 mg. of chloropromazine daily in divided doses for the previous 10 days, and as no other cause for this unusual result could be found, the phenothiazine was considered to be responsible.

Schizophrenic patients given LSD-25 show an increase of psychopathological phenomena and a regression to the prime stage of their psychosis, the manifestations of which seem to be more directly related to the life history of the patients.∗ It has also been observed that some “normal” experimental subjects show various paranoid symptoms with the same drug, but whether these are in any way determined by heredity is not known.

Psychotomimetic drugs have been used increasingly in the past decade for facilitating psychotherapy, most experience being with lysergic acid diethylamide (LSD-25) (Sandison, 3; Savage, 4; Abramson, 1; Cohen, 2). Few attempts have been made to study experimentally their effects on therapeutic interviews, largely because of technical difficulties.

Since it was first reported by Kuhn in 1957, the value of imipramine in the treatment of depressive illness has become generally recognized and confirmed by clinical trials (Blair, 1960; Daneman, 1961; Rees et al., 1961). It continues to hold an important place in therapy despite the introduction of many other antidepressant drugs and the occasional adverse report (Ashby & Collins 1961). Nevertheless the indications for its use are by no means established. It has been claimed that certain types of depression respond better than others: “psychotic” better than “neurotic” (Azima, 1959), “endogenous” better than “reactive” (Ball and Kiloh, 1959). Yet the difficulty of making these categorical distinctions, and of making reliable comparisons between the findings based upon them by different workers remains notorious. It is clear, however, that only a proportion of depressed patients respond well to imipramine. It is also certain that within the group which does respond well are to be found representatives of every type and degree of depressive state. There is evident need, therefore, for information that will help to indicate which characteristics of an individual will render him more or less susceptible to imipramine, and there does not appear to have been any study particularly devoted to this. In this paper we give the results of correlating certain clinical features of depression with the response to treatment by this drug.

Haloperidol is a comparatively new tranquillizing drug synthesized by Janssen et al. (1959). It is chemically unrelated to other drugs acting on the nervous system. It is a substituted butyrophenone whose formula is 4-fluro-4(1-[4-hydroxy-4-(4-chloro)-phenyl-piperidino]) butyrophenone.