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.

It is concerned with the isolation of clinical entities on a psychological basis, and with the investigation of the aetiological factors and psychological mechanisms that may be responsible for these conditions. There is much division of opinion among psychopathologists on basic principles. Particularly is this so regarding the relative importance attached to innate factors, infantile experiences, early training and psychical trauma in adult life in the causation of mental disorder.

This review is based on neuropathological contributions which have either a direct or indirect relation to mental disease or are of major general interest. Notwithstanding these restrictions the field which had to be covered remains vast, and no claim can be made that the survey of the literature is complete, although it is hoped that it is, to some extent, representative. In order to counteract this defect, recent reviews or comprehensive papers on special problems have been recommended, whenever they were available. They will enable the reader to trace references which for lack of space had to be suppressed. For the same reason of economy, a number of quotations have been made from reviews. This does not mean that the original papers have not been consulted.

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.

New methods of physical treatment introduced during the last decade have revived the general interest in schizophrenia, the “Cinderella of psychiatry” (Ellery, 1941). The fact that schizophrenic symptoms can be influenced by crude physical means such as convulsions, hypoglycaemia or operations on the brain has directed the attention to the bodily disturbances underlying the psychological symptoms. The need for accurate assessment of results of these treatments has also revived the interest in prognosis. Kraepelin, who, in 1896, “by a streak of genius” (Adolf Meyer) unified varied clinical pictures in what he called dementia praecox and considered it a disease entity, never doubted its causation by a brain process of organic nature. Nor did Bleuler, when he tentatively proposed the term “schizophrenias” for approximately the same group of cases in 1911 in which he found a common primary psychological disturbance. Those interested in the meanings of “splitting” as expressed by the term schizophrenia will find a discussion of possible misunderstandings in an article by Lewin (1939).

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.

Most of the papers written on depression during the last five years have been concerned with matters which are dealt with by other contributors in this volume—its genetics, biochemistry, social aspects (including suicide), psychopathology, and treatment by endocrine preparations, electrical convulsions, and prefrontal leucotomy. The remaining papers, here briefly reviewed, are few in number, mainly clinical, and do not record any outstanding advances.

The discussion of any topic is handicapped so long as there are doubts and disagreement as to what is being discussed.

To discuss progress in the psychoneuroses without encroaching on the subjects of psychopathology and psychotherapy may appear like an attempt to play Hamlet without the Prince of Denmark. However, there remain certain aspects of aetiology, nosology, differential diagnosis and treatment which are not included in those subjects. It must clearly be understood that the ground covered by the following discussion is strictly limited owing to the above considerations. Thus, psycho-analytic work on the neuroses is to a great extent a matter of psychopathology and psychotherapy, and can therefore find little place in this chapter.

The present war has occasioned sudden and notable changes in many aspects of medicine. Psychotherapy is no exception. The war has come at a time when this branch of treatment is receiving a greater measure of acceptance by the profession than ever before. And the war has brought with it a challenging demand for shorter treatment and—if it may be—more permanent results. Thirty or forty years ago psychiatry complacently limited itself to environmental and custodial measures. Since then a gradual infiltration has taken place whereby the psychiatrist accepts an active therapeutic commission. Much of this change is due, directly and indirectly, to the work of Freud, which shook into animation both clinical psychiatry and academic psychology. The interdependence of these three departments of mental science has by no means reached completion. Nevertheless, psychotherapy can look back on a growing contribution to psychiatry, initiated to a large extent in the Great War, and now multiplied many times by the demands of totalitarian warfare.

Medicine has lately become conscious of the special problems set by the increase of life expectancy following the hygienic progress of the last half century. General interest has been roused in the modification of diseases when they occur in the middle-aged and elderly, and in the illnesses typical of the later periods of life. From this movement psychiatry has profited in so far as many problems of “geriatrics” prove to be psychological and psychiatric problems. Our knowledge of facts has been confirmed and widened and the contact with general medicine should prove fruitful (Malamud, 1941).

In the past head injuries have been of comparatively little concern to the psychiatrist. As judged from statistics of admission to mental hospitals they are a small problem. Mapother (1937), for example, who took a very broad view of the causal connection found in L.C.C. mental hospitials—3 per thousand in observation wards, 4 per thousand in psychiatric O.P. depts. in general hospitals, 7 per thousand of the admissions attributable to head injuries. The increasing interest that psychiatrists take in head injuries at present is mainly due to the increasing amount of extramural work that they are being called on to do. In general hospital and outpatient practice they are bound to encounter a considerable number of problems connected with head injuries, both in the acute and in the later stages. The psychiatrists and neuro-psychiatrists in the Services have probably had this experience first, but when adequate provision of psychiatric service becomes available in the general hospitals, many cases will come into the orbit of psychiatrists which hitherto have been “disposed of” without much regard for their mental aspect.

An extensive review of recent advances in the aetiology and treatment of neurosyphilis was published in this journal by one of us, E. L. Hutton (1941). While it is mainly the later manifestations with their crippling disabilities that present themselves to the psychiatrist in the mental hospital, it is becoming increasingly obvious that early treatment is imperative to obtain good results, and that neurosyphilis itself must be regarded as a preventable disease.

A critical review of work covering a period of years, in three of which war has reduced papers from the Continent almost to nil, must necessarily be incomplete. Lines of investigation, however, follow a pattern which has suggested the following arrangement for this review: (1) Normal development of the child, including the important studies of Gesell (1940, 1942) and Valentine (1942).

The modern usage of the word “delinquency” lacks precision, and some writers use it to connote all types of offences, however serious, and whatever the age of the offender, whilst others restrict its use to minor offences committed by children and young persons. A crime is described legally as an act or omission forbidden by law under pain of punishment (Harris and Wilshere, 1919), and may be regarded as conduct which the State considers to be opposed, at the time, to the welfare of the community. Kenny (1909) stated, “Crimes are wrongs whose sanction is punitive, and is remissible by the Crown, if remissible at all.”

A scrutiny of the papers published during the years 1940-42 and, indeed those published in 1939 and 1943, reveals an increasing trend towards clinical inquiry. Few articles are to be found in which it is assumed that mental deficiency is itself a simple concept, about which little remains to be discovered, and writers are now more cautious in suggesting the best methods of control and treatment than they were wont to be ten or twenty years ago. It is even realized that there are no fully satisfactory methods of describing what is meant by mental defect. Kuhlmann (1941) gives this definition: “Mental deficiency is a mental condition resulting from a subnormal rate of development of some or all mental functions.” The specific functions which are weak or strong in a given case are determined by tests and other observations. As Doll (1941) points out, there seems to be no escape from basing the diagnosis of mental deficiency upon a variety of different criteria, the main symptom still being social incompetence. Standards of social behaviour at different ages have been incorporated by Doll (1942) in the Vineland Social Maturity Scale; he recommends its use in classifying cases for training. The problem of deciding what constitutes mental defect is acutely brought out when differences in education or culture have to be considered. Sparling (1941), for example, showed that American Indian children, whose mean Binet I.Q. was on the borderline between normality and defect, had a mean I.Q. of 108 on the Porteous Maze test. In New York State, Malzberg (1943) found that even allowing for educational differences, mental defect was commoner among negroes than among whites. Nevertheless, as shown by Zubin and Scholz (1941), recognized mental defect (judged by the number of admissions to institutions) is commoner among whites than among negroes in the Southern States. This effect is partly due to the fact that more attention is paid to problems of mental defect in predominantly white than in predominantly coloured populations. Conversely, prisons contain unduly high proportions of coloured inmates according to both North American and South African statistics (Penrose, 1943). The question as to how far mental defect is a contributory factor in cases of crime has received attention from Frankel (1939), who reported that 15 per cent. of 1,000 murderers came into this category, and that the mean mental age for 722 of such criminals was 11 years. Among 309 adolescent delinquents, Stefanescu-Goanga (1939) found 99, of 32 per cent., mentally defective; 47 per cent. of the children committed for homicide were in this category, and 34 per cent. of those committed for theft. Selling (1942) has investigated the degrees of intelligence in offenders under Road Traffic Acts, and finds that although uncomplicated defect is compatible with safe driving, many accidents are caused by emotionally unstable cases with subnormal intellectual capacity, and that such people should not be allowed to drive motor vehicles.