I should like to congratulate the Council of the Section on their decision to devote an evening to a historical subject. I cannot, I fear, congratulate them on their choice of a speaker, for I have done no more than scratch the surface of a very obvious period in the history of psychiatry. However, any sort of historical paper must be better than none, for as far as I have been able to ascertain no such paper has ever been read in this Section, with the exception of the Presidential Address delivered by the late Dr. Hubert Norman. Until a few months ago, exactly the same was true of the Section of the History of Medicine, but in recent months we have had two welcome and refreshing papers by Dr. Burns and Dr. Zelmanowits. We have had, too, the brilliant Maudsley Lectures by Prof. Lewis and Dr. Rees Thomas. Perhaps we may take it that these are signs of a renewed interest in the history of our specialty. I am sure that no branch of medicine needs it more.

Depersonalization remains a subject whose fascination for psychiatric investigators shows no sign of waning. That this is so may partly be due to the striking nature of the symptomatology, though for many the philosophical problems it poses cannot fail to exercise much thought (Lewis, 1949). Numerous aetiologies have been advanced, but there exists no common agreement, even amongst those of similar psychiatric discipline, as to the origin of the condition.

In an earlier paper (Ackner, 1954) various aetiological approaches to the problem of depersonalization were examined and no common agreement was found. The salient phenomena of depersonalization were examined and found to be so lacking in precision that no clear-cut boundaries could be considered to exist. This explained the lack of any truly adequate definition of depersonalization and suggested that some of the past disagreements had been the result of failure to make explicit the phenomena under discussion.

Since there is little general agreement either on the nature of psychopathic personalities or on how to deal with the problems within organized society which their behaviour creates, we are justified in any attempt to present these problems in a new light and to examine the impact of recent work upon them. There is, moreover, an urgent need to clarify our own ideas on the subject in the hope that we can present them in practical form to those social agencies who so frequently meet with the psychopath as a perplexing hindrance to the smooth working of the State's affairs, whether in the schools, the courts, in industry, in the services or in any part of our national life in which planned co-operation is desirable. The psychopathic misfit for whom the increasing complexity of society has allowed no place, and for whom as yet science has found no certain remedy, often manifests his disability at least as much in a disorder of citizenship as in one of personal adjustment, and in no field of our work are we so constantly reminded that it is impossible to consider the patient in isolation from the milieu in which he must live. While the brain is a part, and the controlling, communicating part of the somatic mechanism, the concept of the mind of an individual is not so confined. In that the individual is a member of a group, part of his mental life belongs to that group and plays a part in forming its characteristics. In favourable circumstances this contribution is repaid by the guidance and support which membership of a group can provide. When an individual is so constituted that he is without the inward mechanisms necessary for the efficient working of this process of interchange, the result may be unhappiness for him or loss of harmony in the group. Thus, although it is to medical science that the appeal for an explanation or a remedy is most often made, the psychopathic personality is a responsibility which we must always share with the social sciences. Since the defect of personality is usually a constitutional one, the problems it creates are as likely to be solved by manipulation of the environment of the psychopath than by any effort to change his spots. This is not to say that the leopard in our kraal is not to be rendered more tame, or that he cannot be afforded the help of psychotherapeutic cosmetics, so long as the therapist in his preoccupation with the spots does not forget the savage heart that lies beneath them.

During the last two years, considerable interest has been aroused in the use of chlorpromazine in psychiatry, particularly on the Continent. A full report on the pharmacological properties of the drug appeared in 1953 (Courvoisier et al.), and a short account was given in the first paper describing the effects of chlorpromazine in the treatment of mentally ill patients in this country (Anton-Stephens, 1954). In that study, the drug was administered to patients in several diagnostic categories. A reduction in the disturbed behaviour of excited patients was observed, but considerable variation in response to the drug occurred. Small doses orally were ineffective, and a parenteral daily dosage of 200 mgm. was initially required to produce a clinical response.

Clown: … Nay, I'll never believe a madman till I see his brains.

Substantial contributions to clinical medicine have come from the many accounts of abnormalities in the brains of mental defectives, our knowledge of certain conditions such as epiloia, amaurotic family idiocy and microcephaly being largely based on them. But, in the main, these reports have concerned cases selected for some special interest and few workers have attempted to relate morbid-anatomical changes to the general problem of mental deficiency. The most complete description, chiefly histological, of lesions in the brains of idiots is that of Schob (1930), who summarized in his valuable contribution the wide experience of German neuropathologists. The brains of 120 unselected cases were later studied by Berry (1938), the results being published in an atlas illustrating, case by case, the differences between normal and mentally defective individuals. More recently, Christensen and Vestergaard (1949) presented a short account of a routine autopsy series of 46 mental defectives, finding some structural abnormality in every one of these cases. Other researches covered more restricted aspects of the problem and some of these will be referred to below.

Correlations have been noted between certain persistent personality traits on the one hand and certain patterns within the normal range of variation of the EEG on the other. Some of these correlations had been based on impressionistic assessments of personality, and the following paper contains the results of part of an investigation which was undertaken in order to check these assessments by a more objective method, and to define more precisely some of the qualities reported.

Although the development of factor analysis has led, at least operationally, to more precise description of the field of human cognition, controversy as to the nature of intelligence has not ended, although there has been a marked narrowing of the differences between extremes of view. On the one hand, the monarcheal, or single factor idea, has been superseded by Spearman's two factor theory which has in turn been extended to the consideration of group factors. On the other hand, the multifactorial approach has been narrowed and refined by Thurstonian Multiple Factor Analysis. The primary Mental Abilities described by this method were found to be intercorrelated giving rise to a second order factor which Thurstone has suggested, may be not unlike Spearman's “g”. Despite this basic disagreement as to the nature of the variable under consideration, results obtained have led investigators to almost complete agreement that what they have measured as intelligence is largely genetically determined.

It is recognized that the differential diagnosis between psychosis and mental defect is apt to present difficulties; and the presence of aments in mental hospitals and of psychotics in homes for the mentally defective, though often due to lack of appropriate accommodation, suggests that the diagnostic problem is not always successfully solved. Hitherto, when a certified defective has been found to be psychotic, it has generally been assumed that psychosis has supervened on amentia, defectives being regarded as more prone to psychotic upset than are persons of normal intelligence. The alternative proposition—that mental defect may on occasions be due to psychosis in youth—has received comparatively little attention. This study is an attempt to find out whether psychotic illness beginning in childhood is an important cause of mental defect.

It is generally accepted that any appreciable lack of intelligence precludes the possibility of successful psychological treatment along verbal lines. It is also widely believed that individuals with a lifelong character disorder, commonly described as “psychopathic”, whatever their degree of intelligence, are relatively inaccessible or unresponsive to group or individual psychotherapy. It follows that in individuals where intellectual defect is coupled with psychopathic character, the difficulties of psychotherapy are multiplied. A review of the literature supports this general impression.

Group therapy is one of the more recent advances in psychiatry and is a logical development which fits in well with the spirit of our time. The modern trend in psychiatry is to see the patient not only as an individual but also against his social background. This paper is a factual account of group therapy as carried out in Wormwood Scrubs Prison. The pioneer work was done by Mackwood (1949) and described by him. We should like to acknowledge our indebtedness to him.

Certain specific disabilities following lesions of the dominant hemisphere particularly those involving the parietal region, have been recognized for many years. The syndrome of dyscalculia, dysgraphia, right-left disorientation and finger agnosia is usually known as Gerstmann's syndrome, following that author's descriptions in 1924 and 1940. It has been suggested that of these four main components of the syndrome, finger agnosia might be the fundamental disturbance, bringing the others in its train. Thus, as a result of the postulated importance of the digits for numeration, acalculia would naturally follow. Dysgraphia would result from the loss of the “schema” for the fingers—a part of the body-image—and right-left disorientation might be a consequence of the same body-image disturbance—a “hand” agnosia.

Hypnoanalysis is becoming more and more a recognized psychotherapeutic procedure. It is an analytical type of therapy which utilizes the hypnotic state to reduce the great time and cost of formal psychoanalysis. As with any new form of treatment, there is great variation in the techniques used by different authors (1, 2, 3, 4, 5, 6, 7). This variation ranges from such extremes as attempts to imitate formal psychoanalysis with a hypnotized patient, to mere question and answer interviews interspersed with hypnotic suggestion.

This is the fourth of a series of articles reporting an investigation into the Block Design Rotation Effect. This effect was first observed in some patients while they were doing the Goldstein Block Design Test, in which the subject has to reproduce patterns with the aid of coloured cubes. Some patients, while completing the designs correctly, would leave the completed pattern in a rotated position without apparently being aware of this (2). Such rotation frequently reached 45° (Illustration 1) but rarely exceeded this amount.

Since the publication of Bender's (3) “Visual-Motor Gestalt Test and its Clinical Use” many attempts have been undertaken to validate the clinical findings which she outlined in her Monograph.

In his “Tentative Guide to the Administration of the Bender-Gestalt Test” Hutt (7) did more than anyone else to put into practice the clinical use of the Bender-Gestalt, but his finding on Psychoneurotics have not been confirmed by empirical studies. However, it is of interest and encouraging to find many of the subsequent empirical studies substantiating most of the original clinical uses outlined by Bender and Hutt.

The object of this paper is to present a preliminary report on an experimental unit within the grounds of the mental hospital, but outside the Mental Treatment Acts, for patients suffering from the psychoneuroses. It is necessary, by way of introduction, to give some account of the way in which this unit came into being. One year before it was opened, we became particularly conscious of the problem of institutionalization, and attempted to study the forces active within the mental hospital which lead a patient, for the most part unconsciously, into a state of institutionalization. This is, of course, no new problem; in every mental hospital there is a nucleus of patients, of varying diagnostic categories, who no longer need to remain in hospital on account of the original symptoms or illness which brought them there, but who, under the subtle influence of the institutional life, have become quite incapable of returning to the outside world. This process of institutionalization cannot be dealt with extensively here, but briefly, the forces at work in bringing about this state are felt to be, firstly, those that tend in many minor or subtle ways to relieve the patient of all responsibility for himself, so that he ceases to be aware of the need to tackle his problems seriously, and, secondly, the authoritarian basis of staff and staff-patient relationships which, however benign, requires an attitude of submission on the part of the patient which readily leads to loss of initiative, and to institutionalization. It was, therefore, decided to reverse this process as completely as possible with a small group of patients, to see what further light could be thrown upon the problem.

As Bleuler (1925) pointed out, all our relationships with our human environment are regulated through language. For this, auditory perception is essential, this can only take place if the peripheral auditory mechanism (viz., the tympanic membrane, ossicles, spiral ganglion of Corti and VIIIth nerve) is not diseased. When a person becomes deaf through disease of any of the latter, it does not matter which one of the peripheral mechanisms is involved, the result is always the same. Often not knowing what his fellow men are saying he becomes doubtful about them: losing auditory contact with them he has to rely on an inner world of auditory memories and images; he misinterprets auditory sense impressions which have been distorted by disease, and incorporates tinnitus caused by such disease into his world of inner phantasy. He projects his inner feelings of inferiority caused by his deafness on to his environment and develops ideas of reference. Systematization soon follows, with active delusions of persecution. If the personality is sufficiently unstable a psychotic illness results.