Many problems concerning Alzheimer's disease and Pick's disease are still awaiting clarification. In this country Henderson was the first to draw attention to the considerable importance of Alzheimer's disease in clinical psychiatry. Valuable work has been contributed by various writers in recent years (Grunthal, 1936; Critchley, 1929, 1930, 1931, 1938; Schottky, 1932; Thorpe, 1932; Rothschild, 1934; Malamud, Lowenberg and co-workers, 1929; Mayer-Gross, 1938; Kasanin and Crank, 1933; Jervis and Soltz, 1936; McMenemy, a.o., 1939). While Pick's disease has retained its position as a clinical entity based mainly on the characteristic anatomical picture, the position of Alzheimer's disease in the system of psychiatry has become more complicated; for instance atypical cases have been described presenting the anatomical characters of Alzheimer's disease, though not fitting into the original clinical conception of that disease. Lowenberg and his co-workers (1929) are inclined to regard Alzheimer's disease as a syndrome rather than a clinical entity. Many contributors have directed their main interest to the pathological changes. The knowledge of the symptomatology of those conditions is still incomplete. Further intensive study may enable us not only to base the diagnosis and differential diagnosis of Alzheimer's disease and Pick's disease on more solid clinical knowledge than hitherto, but also to recognize the early stages of those diseases before advancing cerebral degeneration effaces their characteristic clinical features. Unfortunately, most of the cases come under the observation of the psychiatrist only in the later stages of their illness, and it seems that the comparatively small proportion of the mental hospital population they represent does not reflect the incidence of those diseases. It is very likely that many patients die from intercurrent illnesses before their mental condition is recognized or sufficiently advanced to make admission to a mental hospital necessary. The differential diagnosis of those conditions offers considerable difficulties which often may prove insuperable. Alzheimer's disease and Pick's disease have to be distinguished not only from each other but from conditions of vascular origin, from senile dementia and various atypical conditions which occur at the same age period during which Alzheimer's disease and Pick's disease usually develop. Only careful collection and analysis of clinical observations and their scrutiny by pathological investigations can increase our still limited knowledge in this important field of psychiatry.

The purpose of this paper is to illustrate and discuss by case-records the affective responses of a number of patients with a schizophrenic reaction type of mental illness. Recently the energies, time and attention of neuropsychiatrists have been focused on the newer methods of treatment of the schizophrenics. As a result of such intensive and extensive study, interest in other problems of schizophrenia has been rekindled. The “shock therapies” have seemed to crystallize certain factors for us. They have tended to bring out into clear relief certain old factors and have produced many new facts so that we have been forced to re-orient ourselves in many diverse ways. Prognosis has been altered, and this fact has led to a minute scrutiny of the patients who have been treated to determine what factors are operating for or against a favourable outcome. One of these is the affective factor. Patients that have retained a good affective response may still be able to combat reality and its ever-present problems of adjustment and re-adjustment. They may recover spontaneously, or they may do so quicker with the help of the “shock therapies.”

In March, 1939. there was admitted under my care at the St. Pancras Hospital Mental Observation Unit a case of torulosis of the nervous system. This is a very rare disease in this country and the present case is only the third recorded in British medical history (Greenfield et al., 1938; Smith and Crawford, 1930), and the first one to have come under mental hospital supervision. Although such a rarity here, torulosis is more common in the United States, and cases have been reported from nearly every part of the world.

Conscientious objection is a problem involving both personalities and society. It has important military, political, ethical, religious and sometimes psychiatric aspects. It is only where conscientious objection arises in a person who shows signs of psychiatric disorder that the psychiatrist has to take an active professional interest. He has sometimes to treat patients struggling with the problem of conscientious objection and sometimes has to report on them to the Recruiting Medical Boards. Thus this aspect of conscientious objection becomes a part of war psychiatry. My own interest in the problem was aroused by seeing a number of psychiatric patients who were objectors.

The following story was written by a woman writer while convalescing from an attack of melancholia. She had written it for publication as a short story for children.

When I read it, I was certain that it was a deliberate piece of autobiography, written in the form of a fantasy. I was therefore much surprised on putting this to the1 author to be told that it was not supposed to have any reference to herself whatever. Without any attempt at serious analysis it was not difficult to convince her of the real significance of her story, and it is such a good example of the part the subconscious plays in the writing of such stories that it seems worth recording.

For many years the need has been felt for a means of measuring in a reasonably accurate manner the amount of deterioration present in mental patients.

The old criterion of saying that a patient is well because he is capable of working well in the laundry or garden or doing skilful work in the handicrafts department, combined with giving an impression of recovery to the doctors and relatives, is not accurate enough for modern standards.

The value of electrical shock therapy is becoming increasingly recognized and used by psychiatrists in the treatment of depressive states, particularly of the involutional period, states of depersonalization, and to a lesser extent in schizophrenia. One of the major objections to its use, however, has been the complication of fractures, generally crush fractures of the bodies of the mid-dorsal vertebrae (thoracic 4-8), and uncommonly that of limb bones, such as the femur. Another aspect of this problem arises with the occasional case in which the use of shock therapy is desirable, but a previous fracture of the spine or limb bones, or marked bone disease with an increased liability of fracture resulting during treatment, acts as a deterrent to the physician. Even more so is the question of continuing treatment without further damage to the patient, should a fracture have unfortunately resulted before the full course of convulsions is completed. Various methods have been introduced to minimize or abolish the muscular pull producing fractures, including intravenous injections of curare, of concentrated magnesium sulphate solution, or of beta-erythoidin hydrochloride; spinal anaesthesia has been similarly employed.

When von Meduna in 1935 introduced convulsion therapy, his hypothesis that schizophrenia and epilepsy were incompatible diseases suggested that convulsion therapy was applicable only to cases of schizophrenia. Similarly, Sakel, when introducing insulin shock, proposed it as a treatment to be applied essentially to schizophrenia. It is thus not surprising that most psychiatrists at first devoted their main attention to comparing the results obtained from treating schizophrenia by these alternative methods of “shock” rather than in studying their effects on other forms of psychosis. However, Low and co-workers (1) in 1938 reported having obtained very encouraging results from giving metrazol-induced convulsions to a group of sixteen manic-depressive cases, and very shortly afterwards Bennett (2) issued a preliminary report on ten cases of the depressive psychosis in which he stated he had found a remarkable improvement following cardiazol convulsion treatment.

In 1938 Wespi (1) in Germany and Stalker (2) in this country reported cases of crush fracture of the spine following cardiazol convulsion therapy. It was not until then, some four years after its introduction, that attention was focused on the risk of fracture in this form of therapy. During 1939 alarming reports appeared, especially in the United States, regarding the occurrence of such mechanical injury. Polatin et al. (3) radiographed 51 cases following metrazol convulsive therapy and reported spinal fractures in 43 per cent. Bennett and Fitzpatrick (4) in a similarly treated series of cases recorded 47 per cent. spinal fractures. However, the latter figure was obtained from a series of only 18 cases, and should therefore be accepted with reserve. In this country H. A. Palmer (5) in a series of 20 cases treated by cardiazol shock therapy found spinal fractures in no less than 5 cases (25 per cent.).

Damage to the frontal lobe is liable to produce personality changes; it is highly probable that lesions have to be bilateral to have this effect. But beyond that, there is little agreement about type, extent and localization within the frontal lobe of the lesions which are followed by personality change. Little is known about the different types of clinical picture caused by bilateral frontal lesions. In a certain proportion of the cases euphoria is the most impressive symptom, and it is for this reason that operations on the frontal lobes have been proposed in the treatment of depressions. (Lit., see Hutton.) The value of the procedure is still under discussion, and its theoretical foundation is far from being understood. This is not surprising, for if one tries to analyse such an operation, one has to take into account at least four variables: the patient's previous personality, his mental illness, the psycho-physiological effect of the lesion, and the psychological effect of operation, nursing care and environmental changes. The cerebral factor is obviously the most interesting one; to judge its importance one tends to interpret the operative results in the light of experience after other frontal operations or injuries.

It has long been recognized that standardized tests of intelligence, when used with psychotic subjects, cease to be valid measures of native intellectual endowment. This does not mean, however, that it is useless to employ such tests in the study of the mentally ill. On the contrary, the intelligence test still provides us with the best objective measure of the present intellectual efficiency of the patient.