The question whether involutional melancholia in females can be regarded as distinct form of mental illness representing a reaction to bodily changes following the menopause has been amply discussed. It has been held by some that such a melancholia is no more than one phase of the manic-depressive psychosis (1, 2). Others hold the opposite view and justify it on statistical and clinical grounds (3).

A single small aperture connecting each lateral ventricle with the dorsocephalic portion of the third ventricle provides the sole means of escape for cerebro-spinal fluid, and consequently it follows that any interference with its patency will seriously retard the outward flow of ventricular fluid. Complete, or even partial, closure of the foramen leads to a rapid increase in the volume and pressure of imprisoned ventricular fluid so that a condition of internal hydrocephalus is soon established. Usually both foramina are occluded, the hydrocephalus being therefore bilateral and the ventricles more or less symmetrically enlarged. In rare instances, however, only one foramen is obstructed, in which case the dilatation will, of course, be confined to the ipsilateral ventricle. Unilateral hydrocephalus of this obstructive type is commonly caused by inflammatory conditions in the neighbourhood of the foramen, or by pedunculated tumours attached to the choroid plexus which enjoy a degree of movement sufficient to permit intermittent or permanent blockage of the foramen of Monro. It is, however, possible to find examples of unilateral hydrocephalus in which the outflow of cerebro-spinal fluid through the foramen of Monro is unimpeded, and in these the cause of the ventricular dilatation is to be sought in some diseased condition of the cerebral wall which has become so weakened as to be unable to resist even normal ventricular pressure. Such expansion may be either limited to one part of the lateral ventricle, or general, involving the entire body with its horns.

In recent years attention has been drawn afresh to a group of cases in which there is a hyperostosis of the flat bones of the skull, associated with various mental changes and signs of endocrinological disturbances. In 1761 Morgagni mentioned the existence of hyperostosis of the inner table of the skull, and referred to its association with virilism and obesity. Morgagni's brilliant observation was neglected until recently, when it was proposed to name the condition Morgagni's syndrome. F. Morel (1931) published his monograph on frontal hyperostosis of the skull, and expressed the opinion that hyperostosis frontalis interna is a well-defined disease. He suggested that the proliferation of bone is provoked by adhesions between the dura and the inner table of the skull. As characteristics of the syndrome he described obesity, polyphagia, polydipsia, disturbance of sleep, weakness of muscles, loss of sight, headaches, and sometimes epileptic fits. In his opinion a pituitary disturbance is the primary cause of the disease. Shortly before Morel, R. M. Stewart (1928) described cases of insanity with localized calvarial hyperostosis. He found sclerosis of the anterior lobe of the pituitary, which he considered was the responsible cause. Schiff and Trelles (1931) suggested that there might be a relationship with Dercum's disease. Dressier (1927) and Greig (1928) dealt with the pathology of the bony changes. Greig suggests that a disturbance of the calcium and phosphorus metabolism is the causative agent. Critchley (1931), dealing with the neurology of old age, emphasized the importance of hyperostosis frontalis interna. A very extensive series of skulls taken from the average hospital population was investigated by Sherwood Moore (1936), 6,650 in all. In his case material there was 1.4 per cent. of hyperostosis. He tried to classify hyperostosis into four forms.

The comparatively old belief, that the epileptic patient shows a retention of water before the onset of a major seizure and an increase in the water excretion afterwards, achieved great importance from two findings of more recent date : on the one hand, the frequency of the seizures may be increased on hydration of the organism by administration of excessive amounts of water in combination with antidiuretics; on the other, the frequency may be decreased on dehydration either by restriction of the water intake or by other means (see for example Fay, 1929, 1930; McQuarrie, 1929; McQuarrie and Peeler, 1931; McQuarrie et al., 1932; Engel et al., 1934; Clegg and Thorpe, 1935; Stubbe Teglbjaerg, 1936; Ziskind et al., 1939; Hagenmeyer and Langelüddeke, 1939; but contrast Cameron, 1931; Fetterman and Kumin, 1933; Wilson and Limberger, 1933; Stone and Chor, 1937; Pette and Janzen, 1938). It is therefore most desirable that the value of the evidence connecting water balance and the occurrence of spontaneous seizures should be assessed.

The part played by sex hormones in the genesis and pathology of mental disorders is still the subject of striking differences of opinion among psychiatrists.

Schizophrenia may conservatively be listed among the greatest scourges of present-day society, yet the average citizen has scarcely heard of it.

“The etiology … is unsettled; its pathology unknown and its clinical limits in dispute and yet it is a more serious problem than either tuberculosis or cancer. There are twice as many hospital cases of schizophrenia as of tuberculosis. Each year not less than 30,000 to 40,000 individuals, soon after adolescence or in the first flush of manhood or womanhood, fall victims to this condition. Annually 75,000 new patients are admitted to state hospitals and at least one fourth are schizophrenics…. They are condemned to a veritable living death, devoid of emotional life as others savour it and barred from participation in the normal activities and affairs of living” (1).

The object of this paper is to test the following two hypotheses:

1. 1. That the physique of female adults can be regarded as the resultant of two independent modes of variation, one determining differences in size or bulk, and the other determining differences in proportion or type.

2. 2. That a relation exists between schizophrenia and manic-depres sion, on the one hand, and differences in physical proportion or type, on the other.

The experimental reproduction of psychotic phenomena in the normal person is a subject which has attracted much attention in recent years from psychiatrists, and which has added remarkable and interesting facts to our clinical knowledge.

The development of psychological medicine in Great Britain has been accompanied by a certain feeling of inferiority amongst psychiatrists and psychotherapists. This has shown itself in rivalry, at times brisk and even acrimonious, which may be understood as a striving to obtain the object which another is thought to be pursuing. This state of affairs arises when there is uncertainty of objective; and all will agree that the objectives have been ill-defined and at times nebulous. Here as elsewhere the familiar characteristic has been” muddling along somehow When we come to consider possible reasons for this, one feature stands out, namely, the lack of originality in our insular school of thought. We have produced no Copernicus to revolutionize our methods and systems, and so sweep away intellectual vested interests. To meet the needs at home we have built up a national debt by borrowing. Our source of inspiration has been largely Continental. Freud, a little bitterly perhaps, alludes to ‘1 the numerous psychiatrists and psychotherapists who warm their pot of soup at our fire — without indeed being very grateful for our hospitality “(I). The genius of Freud and of Jung lay in speaking from the heart and setting at naught traditional views. Their very different contributions have been so refreshing that many accepted, without questioning, the teaching of one or other of these pioneers. Others rejected in toto (and often unread) what was described as “the new psychology But a more hopeful note has recently been sounded in this country; for the question of method, or way by which we proceed to the attainment of some aim, has been the subject of numerous contributions; and less attention is being paid to the technique embodied in the method. In this paper certain suggestions upon methodology will be made; and the subject will be examined critically, especially from the clinical aspect.

In his book, Psychology and the Soldier, which gives a critical estimate of the psychologist's contribution during the last war, Bartlett (1) makes an interesting statement which takes on new meaning at the present time. Commenting on the fact that intelligence tests may safely “rule out a man” from participation in activities which may endanger the group, he queries whether a man can as simply be “ruled in” for filling a responsible position. “For practical purposes,” Bartlett says, “temperament is a more important factor in success than intelligence, as the latter is understood in the mental test movement. Slight variations in temperament may make a bigger difference to a man's practical value in any social organization, such as an army, than large variations in intellectual processes. No doubt much can be done by psychological examination to discover a man's real temperamental qualities; no doubt a psychologically skilled or a psychologically trained observer can detect such qualities speedily and with reasonable accuracy. But the satisfactory direct temperament test has yet to be devised, and very likely never will be found.”

While a vast literature refers to anomalies in various arteries of the brain, there are only a few reports concerning anatomical changes of vessels following altered circulatory conditions. Critchley mentions in his study of the anterior cerebral artery and its syndromes, an observation in which an arterio-sclerotic anterior cerebral artery of one side was so small as to be incapable of maintaining an adequate circulation, so that by way of an abnormally large anterior communicating artery the opposite anterior cerebral supplied both hemispheres. Critchley adds to that case several similar observations from the literature. The application of arteriography to circulatory disturbances has directed attention to analogous cases. Thus Moniz reported several observations in which a closure of the carotid artery of one side led to a distension of the anterior communicating in order to establish collateral circulation. The same mechanism appeared to be effective in the following two cases which we met in the course of our studies on brain vessels.

In the world of mental diseases schizophrenia may well be termed “the sickness that destroyeth in the noonday.” Although the replacement of Kraepelin's nomenclature of “dementia praecox” by Bleuler's term, “schizophrenia,” has carried with it a general recognition that the chance of recovery is better than had been originally anticipated, the doom of those who do not recover is amongst the most dreadful meted out by any disease. It so frequently means a body apparently fully alive with a mind permanently impaired or virtually dead. Despite the obvious desirability of assessing the prognostic chances of the individual case, the statistical works published up to date have failed to establish agreement as to how this may be done. The object of this paper is to combine a detailed examination of the literature with a personal study of the histories of over 100 cases of schizophrenia in an effort to reach a definite conclusion in this matter. The paper will be divided into the following parts: I, a detailed survey of the literature; II, the outcome of 120 cases studied by myself; III, a comparison of remission rates and prognostic factors in cases treated by cardiazol.

A survey of the creatine and creatinine excretion of large numbers of mentally defective patients in circumstances which precluded both keeping them on creatine-free diet and the obtaining of 24-hour specimens, led Penrose and Pugh (1939) to the use of the creatine creatinine ratio in early morning specimens of urine as an index of the metabolism of these substances in each patient, as compared with controls. The use of the ratio was found to yield results of qualitative significance. Patients suffering from conditions known to affect creatine-creatinine metabolism, such as muscular dystrophies, diplegias, and hyperthyroidism, were readily picked out, and the creatinuria of children was marked; conclusions could be drawn as to the creatine-creatinine metabolism in certain other conditions. In the above survey the numbers allowed of statistical treatment to a considerable extent, and this confirmed the validity of the conclusions drawn from the ratio.

In a study on chorea, tics and compulsive utterances, Creak and Guttmann (1) discussed some problems of the inter-relation of organic neurological and neurotic symptoms. They showed that residuals, latent or manifest, of neurological diseases of the motor system may be instrumental in shaping the clinical picture of neuroses. There is generally no difficulty in demonstrating such interrelations, if the neurological anomalies are of a well-known type and clear cut in onset. Pareses, peripheral or central, or aphasic disorders, are generally not difficult to recognize where they are the nucleus of a neurotic picture, and not much objection is encountered if one tries to assess their importance, pathogenetic or pathoplastic, in a given clinical picture. This, however, is difficult where less well known syndromes are concerned, such as apraxic or agnosic pictures, or where beginning or end are gradual and the whole picture less clearly defined, as in disturbances of the extra-pyramidal motor system. To recognize an early stage of Parkinsonianism within a depression or other “neurotic” illness is not easy. The same is true of mild extra-pyramidal hyperkinetic states, partly because they may be so similar to normal movements (pseudo-purposeful), and partly because the milder anomalies as seen in early or later stages (and in abortive cases) are little known.

The way in which schizophrenics react to physical illness and injury is a problem worthy of study, especially at the present time when schizophrenia is being so widely treated by methods which bring about profound changes of the physical state. Although schizophrenics, recent and chronic, are very susceptible to physical illness and form a considerable part of the sick population of the average mental hospital, this question has not attracted a great measure of attention. A survey of the schizophrenic population of a mental hospital suggests that there is an apparent lack of specific psychotic reactions to physical illness, so that it would seem as if schizophrenics react to physical illness either in a normal way or more commonly with indifference. It is true that certain paranoid patients include complaints of physical disturbances in their systems of delusions, but as a rule, even in these cases, there is no specific reaction to physical illness, which like other experiences enters into the world of imagination in which the patient exists.

The problem of the differentiation between neurosis and psychosis has given rise to much confused literature and discussion. This is particularly true of those cases in which anxiety or depression is the outstanding feature of the illness, and which do not show any gross symptoms of psychotic illness. Such confusion as exists appears to be due to a variety of causes. For example, the social implications of psychotic illness tend to favour a diagnosis of neurosis in many of the milder cases. Again, the same diagnostic terms are often used with quite different meanings by different workers. An even more potent cause of difficulty is the temptation to search for fixed disease entities in psychiatry which can be sharply separated one from the other.

During recent years so much has been written about convulsive therapy that it would seem rash to burden still further the very extensive literature on this subject. Nevertheless, in spite of the admirable work that has been done, it cannot be said that the implications of convulsive treatment are fully understood, nor that the fullest possible use has been made of this treatment for research into the pathophysiology of epilepsy. Furthermore, the recent introduction by Cerletti and Bini (1) of a method of treatment with electrically produced epileptic fits has increased still further the scope of research. I have had at my disposal case material provided by the treatment of various forms of mental disorder with cardiazol for more than two years, and with the electrical method in collaboration with Mr. Grey Walter for about six months. This has enabled me to conduct certain investigations of a sort that have received little or no attention hitherto, and to make observations covering various aspects of the physiology and psychopathology of induced epileptic states.