In discussing the late stage of head injuries, it is necessary first to define the clinical stages in the treatment of these conditions. With Donald Munroe, it is considered expedient to classify cases of head injury in general into— (a) Operative and (b) Non-operative cases.

Protagonists of mental tests in clinical practice have hitherto shown a decided preference for methods of examination adapted to study capacities already developed or knowledge already acquired. Relatively little attention has been given to the study of learning, despite the fact that this function is so obviously affected in many and various neuropsychiatric conditions. One need only recall the widespread loss of plasticity so characteristic of the dementias and the more specific defects of learning associated with various types of focal lesion, e.g. of the language centres or the visual-association areas (cf. Cobb, 1944, pp. 214–5; Zangwill, 1945). It may therefore be urged that any technique of studying learning that is objective in character and easily adapted to the needs of routine clinical examination is worthy of attention. One technique which meets these demands will be described in the present paper, together with a small selection of the results obtained on routine psychological testing at the Brain Injuries Centre in Edinburgh.

The problem of mental disease has been approached in many different ways, and chemical, anatomical, biological and psychological methods have been employed. In certain cases it has been possible to obtain satisfactory results by the use of one isolated method: the serological and anatomical approach has given us a useful solution to the problem of general paresis; the genetic approach has been equally useful in the study of mental deficiency. Such great results may explain the prevailing tendency in psychiatric research to attack all the problems of mental disease by the systematic use of one single method, in the hope that the final result is only a matter of time and of technical refinement. One author believes in the anatomical approach, another in the chemical; and there is a tendency to exclude other” methods, in the belief that they cannot give results of basic importance. Psychiatry also has its eclectics, but generally the most intensive research work is carried out by the various “schools,” and with a definite exclusiveness of methods.

This investigation was carried out at Belsen between May 21 and June 27, 1945. As it was impossible to examine psychiatrically all the cases, only those showing evidence of psychological upset were referred for examination by the physicians. In addition, to obtain a cross-section of the population, I selected at random 60 to 70 cases in hospital and convalescent areas—ones that did not fall into the first group.

In the relatively short period which has elapsed since the important findings about personality changes after encephalitis epidemica became known, those findings have been mainly responsible for the enormous advance in our knowledge of the sub-cortical direction of man's emotional and volitional life. This advance in psychopathology subsequently gave rise to the question whether similar sequelae could be found in the personality structure of those who had suffered from other forms of post-infectious encephalopathies. Chorea, which had already offered the puzzling problem of why the rheumatic virus becomes “neurotropic” in certain cases, was amongst the first to be considered, whereas 25 years ago no psychiatrist would have seen a special problem in the personality structure after choreic illness. The first investigations which dealt with entirely new problems in chorea minor were those of E. Straus, (1927), who found that hyperkinetic symptoms are frequently found, either in a generalized form, or as localized tics as sequelae of chorea minor, and of E. Guttmann (1927) and Schulz (1928), who both showed that hereditary predisposition of the brain plays an important role in persons who fall ill with chorea minor. A follow-up study of chorea cases with regard to personality development had not been undertaken until the present author's first publication on chorea (1934).

The problem of tuberculosis amongst mental hospital patients is of importance from both the psychiatric and public health point of view. Most of the active methods of psychiatric treatment must be abandoned or discontinued when physical illness intervenes. The problem is even more far-reaching from the standpoint of public health. Wingfield, Trail, Banks and McDougall (1942) have estimated that there is probably a reservoir of 250,000 infectious cases recognized and unrecognized in England, Scotland and Wales, and several authors have pointed out that mental hospitals contribute a disproportionate number to this reservoir. Modern methods of mental hospital administration with parole and leave privileges applied to the maximum number of patients lend importance to the public health aspect, not only the patients themselves and hospital staff being menaced, but also patients' visitors and relatives and other contacts outside hospital. The incidence of tuberculosis in mental hospitals has been variously estimated at 5 to 10 times and the mortality in peace-time 8 or 9 times that of the general population. These figures are sufficient to justify all efforts to bring the problem under control.

Fly-bombing is not always concentrated, for isolated explosions may occur at any time. There are also numerous if uneventful alerts. Thus there is a state of continuous uncertainty which might be expected to affect psychoneurotics considerably. I therefore set out to investigate the reactions of my patients during approximately ten weeks' concentrated fly-bombing. There were 620 soldiers—9 male officers and 121 auxiliaries—a total of 750 cases, all stationed in the London district. They were referred to me for various psychiatric reasons, by no means on account of anxiety due to bombing; nor was referral on account of fear of bombs necessarily indicative of special apprehension on the part of the patient—in some cases indeed it obviously only indicated anxiety on the part of those making the referral!

In a previous investigation it was found that the incidence of schizophrenia in a group of 627 British N.C.Os. was much lower than in the average O.R. admissions to hospital. Two questions at once arose: Why was the incidence of schizophrenia low? and How does the disease incidence of British N.C.O. psychiatric casualties compare with other groups admitted to this Base Psychiatric Hospital? The answer to the first may become apparent when we have found the answer to the second.

A discussion of the use of prolonged narcosis in mental disorder might seem to be something in the nature of a valedictory address. The ease of application of electric convulsion therapy (E.C.T.), and the excellent effects of its use (1, 2, 3, 5, 11, 25, etc.), particularly in melancholia, have tended to overshadow the benefits to be obtained from an efficient narcosis clinic.

Although the electrical treatment of mental disorders is still in the empirical stage, its use is well established. Certain features and principles of treatment have been elucidated in the published reports, and all are agreed that it is specific for melancholic states.

The evaluation of the scope and usefulness of E.C.T. would be enhanced by the comparative study of case material from various clinics, but much in the published reports is not strictly comparable because of the unavoidable variation in the assessment of diagnosis and the degree of recovery. In our case material collected over a period of five years we have endeavoured to present the facts with a minimum of subjectivity by limiting our observation as far as possible to measurable data. In order to reduce the variable factor of diagnosis, some 700 psychotics treated with electrically induced convulsions have been reconsidered and 500 selected for analysis after carefully excluding the overlapping types, particularly those cases presenting features of both affective and schizophrenic psychoses. The selected cases can therefore be regarded as classical examples clearly separated into the two large groups of biogenetic psychoses—schizophrenic and manic-depressive, including involutional melancholia.

Since the influence of the autonomic nervous system on epileptic phenomena became the subject of intensive investigations, several contradictory reports have been published. Williams and Russell (1941) and Williams (1941) found that parasympathetic overactivity (induced chemically and registered by electro-encephalography) increases epileptic activity. Darrow (1944) reported opposite results, his observations being based on electrically induced parasympathetic overactivity on animals. He registered his observations by electroencephalography. Cohen, Thale and Tissenbaum (1044) induced convulsions for therapeutical purposes by administering the parasympathomimetic drug, acetylcholine, and Chatfield and Dempsey (1942) observed the production of fits in cats, when giving acetylcholine and prostigmine together. Though the results were contradictory, the main aim of all these investigations was to establish the cholinergic neurohumoral changes in relation to epilepsy. But, as Williams pointed out, it is impossible to say whether the results are due to a direct central action, are consequent upon changes in the pH or of a respiratory or a circulatory nature. The investigations described in this paper were devised to re-examine these problems clinically. They were based on the hypothesis that if cholinergic overactivity enhances epileptic cerebral activity, the convulsive threshold of the brain should be lowered after administration of anticholinesterases, in particular prostigmine.

The psychiatric aspects of ageing are a major problem in any country which, like our own, has a low net reproduction rate and a high standard of social responsibility: the proportion of old people in the community steadily increases, so that they provide an increasingly high proportion of our mentally infirm population who must be cared for. But it is not only senile dementia and the other senile and presenile psychoses described in textbooks that make up the problem: less conspicuous failings which may accompany old age also call for attention if the social and preventive sides of our work are to be given due weight. Therefore it is psychiatric aspects of ageing rather than senile psychoses alone that are intended by the title of this paper.

Perhaps the earliest adumbration of modern interest in problems of old age was Quetelet's important two-volume work on Man and the Development of his Faculties in 1835 (55). In this book appeared for the first time data of a kind since become very familiar: ages when various crimes are committed, when literary masterpieces are written, ages of admission to hospitals for the insane, and so on.

The object of my study was an attempt to discover what social factors might be said to contribute to either mental health or mental ill-health in old age. I studied the histories of four groups of 50 aged in four different settings which in retrospect might be said to form a spectrum. That is to say that each subsequent social background seemed to be more conducive to normal ageing than the preceding one. The actual sequence of the whole investigation, for technical reasons, was, however, as follows: In the first place I made contact with patients in Tooting Bec Mental Hospital; as a second group I chose people in a Club for Old Age Pensioners in Streatham; thirdly, I visited old people living by themselves in Fulham; and finally, 1 interviewed a group who are living on an Estate at Mill Hill, the Estate being maintained by the Society of Linen and Woollen Drapers. In all but the last sample I studied the cases of 25 men and 25 women.