A number of studies have been recently concerned with the clinical application of the Archimedes spiral, an illusory negative after-effect of apparent movement, which requires no description here. Freeman and Josey (3) reported a relationship between the presence or absence of this after-effect and a clinical judgment of memory function, while a cross-validation study by Standlee (11) failed to confirm this observation when an objective measure of memory impairment was used.

Depersonalization, derealization, unreality feelings, metamorphopsia and similar symptoms are not unusual in neuro-psychiatric patients. They are said to be extremely rare in children, Tramer (22) does not mention them, and Kanner (9) remarks only that “feelings of unreality are exceedingly rare in children. Things seem unreal to the patient, different from what he knows them to be. He is fully aware of the incongruity of his experience, which sometimes causes considerable distress.” He quotes the case of a slightly retarded boy of almost 14 years who combined feelings of unreality and derealization with occasional macropsia.

By 1975 Denmark should have 9 new mental hospitals, each, with one exception, closely linked to a general hospital. This is the most striking of the proposals contained in the Report∗ of a Commission set up by the Danish Ministry of Internal Affairs in 1952. This Commission was to “report on trends of development of the State Mental Hospital Service in respect of organization and buildings, with special reference to the necessary adaptation of the hospitals to present-day needs and forms of treatment. The Commission's deliberations, which should principally be concerned with the modernizing and extension of the hospitals together with their position in relation to the general hospital service, should also include the possible extension of treatment to categories of patients with mental disorders other than true insanity. The Commission's work should be so arranged that its report can constitute the immediate foundation for the practical organization of future reform work.” This Report contains much of general interest and much which might merit wider application.

Increasing use of the Rorschach Inkblots Test is being made in medical diagnosis, not only in psychiatry, but in neurology as well. Bibliography is too extensive to quote here, and the reader is referred to the standard work by Klopfer et al. (1956) which lists nearly 3,000 references specific to Rorschach literature. The inclusion of a long chapter on the clinical use of this test in the latest research monograph of the Association for Research in Nervous and Mental Diseases (1954) is evidence of the increasing esteem in which this test is held by specialists in neurology and psychiatry, supported by the growing use of the test in diagnosing intracranial organic pathology. It is interesting to note that in the latter field the Rorschach has proved superior in diagnostic accuracy to any other single neurological test, such as EEG, lumbar puncture, ventriculography, etc., and is often as good as the complete battery together.

Schizophrenia occurring in the early years is generally recognized to be a deteriorating illness and one in which therapy has little effect. Tredgold (6) recognized schizophrenia as a cause of oligophrenia and most mental deficiency hospitals have a number of these patients. Although not numerically a large problem, they are among the most difficult patients to handle.

It is often of importance in a psychiatric department to ascertain whether a patient has consumed the Largactil prescribed, e.g. on occasions when a patient appears only to be slightly affected by Largactil. Dubost and Pascal demonstrated that a Largactil solution mixed with equal quantities of concentrated sulphuric acid gives a marked carmine red colour which is so stable that the intensity of the colour may be measured in a spectrophotometer. In biological fluids, Largactil must first be extracted with ether and then transferred to the aqueous phase before the determination can be undertaken. By experiments on rabbits and dogs, these authors found that up to 5 per cent. of the Largactil administered is excreted in the urine in the course of 24 hours and a total of up to 8 per cent. is excreted in the course of the first few days.

The preparation of the men to staff the psychiatric centres and services, the laboratories and installations which have come into existence in such numbers and within so short a period in almost every country has been a task of the first magnitude.

For the past twenty years we have been studying methods of teaching and their effectiveness in changing the behaviour of medical students and doctors. At the Massachusetts General Hospital our work was concerned primarily with teaching psychotherapy to medical students, residents and younger physicians. During these years we have practised and taught many kinds of psychotherapy, including situational therapy, relationship therapy such as catharsis, support, reassurance, suggestion and persuasion, and the various types of insight therapy from the verbalization and understanding of simple correlations to more extensive Freudian psychoanalysis. The patients we treated in Boston were primarily those with psychoneuroses and psychosomatic disturbances. In these groups of patients insight therapy was the method of choice. It was only when insight therapy was impracticable or too disturbing to the patient that other methods such as relationship therapy were used. During these years we used insight therapy whenever possible, often with limited effectiveness. The treatment for any given hospital admission required from 20 to 40 interviews, occasionally more. It was our practice to use the vis-à-vis interview method.

A series of studies published since 1951 attempted to clarify what is meant by the neurotic in human nature. In returning to this problem today, I must beg your indulgence for repeating myself at some points. Apart from the kindness of your chairman in inviting me to discuss the Neurotic Process as my contribution to this symposium, my further justification is the opportunity which it gives me to add a few considerations which may round out the hypothesis and make it more useful, and also to indicate that the neurotic process is the meeting place for the organic and psychological approaches to problems of human behaviour (4, 5, 7, 10).

It seems to me proper to stress from the beginning that there are various types of depressions. Often they are ill-defined, while at other times they fit into the clinical entities of manic-depressive reactions or later-life (involutional) groups. In addition, psychoneurotic depressions are also recognized. However, the essential nature of all these types of depressions is still poorly understood. Treatment therefore cannot be based on an aetiological concept or be specific for depression, but must be based on the psychopathological data.

It is good to be back in the serenity of this assembly after an interval of ten years, but I must ask your forbearance in view of the fact that the topic assigned me today is rather similar to the one I discussed here in 1947.

It has been stated too frequently that new therapeutic developments in psychiatry are revolutionizing the field. While this did not turn out to be true for any of the treatment procedures, it can well be stated that those of us who entered psychiatry more than 25 years ago, lived through a period in which psychiatry changed from a specialty known for its therapeutic nihilism to a field of almost feverish therapeutic activity. Undoubtedly the physical treatments have played a decisive role in this change. They have also clearly changed the attitude on the part of the individual psychiatrist to his specialty. Our teachers were primarily concerned with attempts to organize and systematize our knowledge, while our generation, perhaps because too pragmatic, may easily be blamed for failure to link the newly-acquired information with the basic concepts developed by them, concepts which were neither confirmed nor disproved by our new knowledge. When I think of my own development as a neuropsychiatrist, I remember that I started out in psychiatry, but temporarily turned to neurology because at that time neurology seemed to give much greater therapeutic possibilities. It was only in the middle nineteen-thirties that this changed radically, and that so many more therapeutic possibilities developed in psychiatry that it became a challenge to return to this field. The introduction of the various physical treatments in close succession was an amazing coincidence. Although met by some with scepticism and even ridicule, and by others with unjustified over-enthusiasm or a competitive attitude improper for scientific progress, the new treatments evoked a beneficial optimism among psychiatrists. They helped to change the attitude of the mental hospitals in all countries and gave an entirely new impetus to the general public to become interested in matters concerning the mentally sick. It may also be said that the physical treatments gave a new stimulus to efforts at psychological and social treatments of the psychotic patient, and I dare say that the improvements in mental hospital management which are so conspicuous in your country could not have progressed so fast and met with so much public support if the physical treatments had not helped to improve the adaptability of patients in these hospitals. It is a historical fact which can be easily proved, especially in England, that those hospitals which are now the showplaces for modern hospital treatment, with open wards and social and recreational activities for almost every single patient, are also the ones in which pioneer work was done with insulin coma treatment, convulsive treatments and psychosurgery. I am going to discuss these treatments, while the newest approach, pharmacotherapy, will be left to another report and be mentioned only as far as it influences the application and indications of the other treatments.

I should like to discuss some of the clinical aspects of the tranquillizing drugs, but without going into great detail as to the many theoretical considerations in biochemistry, physiology, pharmacology, etc. which have been ventilated so often in connection with this form of treatment.

It is presumptuous for a clinician to embark on this subject, and I hasten to apologize for my boldness in doing so. My excuses are many. The first comes from clinical experience. Since my student days, when I observed malignant schizophrenia in a young girl for the first time, and watched its relentless progress despite all therapeutic efforts, I came to the belief that this was an illness of body as well as of mind, and this belief has led me to maintain a continuing interest in the medical, as distinct from the purely psychological, investigations of this disease throughout my professional years. Next has been the observation of experimental or model psychoses produced by drugs. An LSD or mescaline psychosis is not schizophrenia, any more than curare poisoning is myasthenia gravis, but there is enough similarity between the dissociation states produced by psychotomimetic drugs and the real thing to stimulate one's curiosity, at least.