In choosing a historical subject, the easiest thing to do is to look for centenaries, and it so happens that the year 1859 was an eventful year in British psychiatry and is moreover a specially well-documented one, and further that the events and opinions thus documented seem to have a particularly topical interest for us today. In the first place, there was published in 1859 the book to which the title of this Address refers—On the State of Lunacy, by J. T. Arlidge, sometime Resident Physician to St. Luke's Hospital, a unique discussion of the problems of mental illness as they appeared to progressive specialists of the day. Secondly, an attempt to introduce fresh legislation led in February, 1859, to the appointment of a Select Committee of the House of Commons, which issued its report in the following year. Thirdly, the Annual Reports of the Commissioners in Lunacy for the years around 1859 are especially illuminating. In 1858 they sought to overcome the “dogged and passive resistance” of the parish authorities—of which more hereafter—by issuing a Supplement to their Report constituting a full and convincing indictment of the treatment of mental patients in workhouses and workhouse infirmaries; and their Report for 1859 contains an account of the London Licensed Houses. Again, it so happens that the Presidency of what is now the Royal Medico-Psychological Association, but then existed under a more humble name, was held in these years by four outstanding personalities—Forbes Winslow in 1857, followed by John Conolly, Sir Charles Hastings and Dr. (afterwards Sir John) Bucknill, all of whose inaugural Addresses reflect the ideals and practices, hopes and anxieties of their fellow-members. I should add here, but it would be beyond my sphere to refer to it any further, that following Dorothea Dix's visit to Scotland, and the institution of the Scottish Commissioners, the early Reports of that body give full descriptions of the state of affairs there, and of the rapid improvement brought about by Dr. W. A. F. Browne and his colleagues.

For a long time epidemiology was a term associated with the study of outbreaks of disease which were sudden and large-scale. The attempt to find common causative agents to which the majority of cases could be attributed has provoked a literature worthy to rank with some of the best detective fiction. So many of the guilty agents have now been either liquidated or rendered impotent that infectious illnesses have ceased to occupy the centre of the public health stage, and have yielded place, as objects of concern, to such chronic diseases as cancer, rheumatism, heart disease and the schizophrenias. These diseases do not generally show explosive outbreaks, although mental disorders have been known to behave in this way, as witness the outbreaks of Dancing Mania which originated in Italy in the thirteenth century. All this has led to a more exact concept of epidemiology as “the study of the distribution of a disease or condition in a population and of the factors that influence this distribution” (Lilienfeld (1)).

For many years both clinicians and researchers have been interested in the thought disorders found in schizophrenic patients. Bleuler (4) believed that “weakness” or “looseness” of association was the primary disorder in schizophrenia. However his views were based on the associationist approach to the theory of thinking, which was buried a long time ago by the advent of Gestalt psychology, and even before that by the work of the “Denkpsychologie” school of Würzburg. The founders of the Würzburg School, Külpe, Ach, Watt and Marbe (31, 1, 56, 34) showed conclusively that the thinking process cannot be reduced to association of ideas and they introduced the concepts of “aufgabe” and of “einstellung”, which represented some kind of imageless directional and selective influences in the thought process. A suggestion was made by Paul Schilder (47) that it was this super-ordinate directionality and selectivity of thought process which was affected in schizophrenia. An attempt to apply the principles of formal Aristotelian logic to schizophrenic thinking was made by Von Domarus (17) who found that schizophrenics tended in their propositions to identify the subject with the predicate.

Anxiety, either manifest or in the form of non-specific emotional disturbance, has been widely accepted as an operative factor in the personality structure of delinquent subjects (Aichhorn, 1; Burt, 5; Friedlander, 17; Stott, 53), and at present it appears that cognitive factors have little or no bearing upon the problem (Marcus, 43; Woodward, 61). By regarding anxiety or activated stress as a stimulus producing response (Hull, 24, 25; Miller, 45), delinquent behaviour has been postulated as learned responsiveness to anxiety or stress, which also functions as a learnable drive (Tong, 55). Previous investigations using Rorschach, persistence and galvanic skin response indices of anxiety or emotional disturbance have shown that there are significant variations according to both the nature of the conduct disorder (sex, violence, larceny, etc.), and ratings of stability (Tong, 54, 55). Different forms of conduct disorder are also known to carry different relapse potentialities, so that sex offenders, for example, are less likely to relapse than are larceny offenders (Mannheim and Wilkins, 42; Tong and Mackay, 60), although it is possible that different methods of treatment or disposal influence the likelihood of relapse for different sex offenders (Radzinowicz, 48). Prediction tables have been constructed for the purpose of more accurately assessing the most unstable offenders (42), and although such systems carry an encouraging degree of reliability it is apparent that greater reliability in prediction will only follow more accurate personality assessment than is possible by the use of impressionistic methods alone (58). Only knowledge of the relevant personality variables will lead to accurate assessment of change in subjects for whom the significant historical factors necessarily remain fixed. Furthermore, assessment techniques must be relatively unaffected by intelligence, education and rapport factors.

Susceptibility to drugs is a biological variable, and Clark (1933a) remarks that for organisms sufficiently large to permit measurement of individual dosage, the curves relating dose and incidence of effect are sigmoid and can be assumed to express the individual variation of the population. Some of the variables determining drug response include age, sex and body weight (Goodman and Gilman, 1955). Although a relation between personality and drug response has always been alleged, Kennedy (1957) alluded to the lack of work in this field.

This paper reports the results of a series of psychological tests and behavioural scales obtained upon psychotic patients who were given prefrontal lobotomies at the Palo Alto Veterans Administration Hospital during the years 1947 through 1954. Psychological testing procedures were administered both before and at given intervals following operation, and comparisons were made of the pre-operative measures to degree of improvement. Also, an evaluation was made of changes in the measures over time following lobotomy.

During an investigation of the morbid anatomy of pituitary and adrenal glands of an unselected series of mental hospital patients (1), it was noted that adrenal sudanophilic material and birefringence were reduced in many cases of schizophrenia. It was therefore decided to make a statistical study of such cases in order to determine if any significance could be attached to the findings and if so, to consider how the facts might be related to present knowledge of schizophrenia.

The value of a rating scale for assessment in psychiatric disorders is that it facilitates the investigation of patterns of symptoms and their response to treatments. In a previous paper, Hamilton (1959), describing the construction and use of a rating scale designed for assessing the condition of patients suffering from depressive disorders, certain findings were described. In brief, it was found that much of the information given by the 17 variables of the rating scale could be given by four “index numbers” (dimensions, or factors). The nature of these factors was determined in two ways. In the first, the weights given to the symptoms which constituted the factors were examined. It was found (Table I) that the highest weights in the first factor were given to Depressed Mood, Guilt, Retardation, Loss of Insight, Suicide and Loss of Interest, in descending order. On this basis it was decided that the first factor corresponded to the classical clinical description of Retarded Depression. Examination of the weights given to the symptoms in the second, third and fourth factors, showed that these factors had no obvious correspondence with clinical syndromes.

May I begin by qualifying the title of this paper? I can only illustrate some broad principles and a few of the methods that are used in epidemiology today—there is no attempt to be comprehensive.

Because of the importance of the serum lipids in the pathogenesis of atherosclerosis, much information is available on the serum lipoproteins of adults in health and disease (Adlersberg et al., 1955; Chapin, 1956; Dangerfield and Smith, 1955; Jencks et al., 1956; Kanabrocki et al., 1958). The lipoproteins in childhood have been studied less extensively. Rafstedt (1955) has reported lipid and lipoprotein values for normal infants and children. More recently, Salt and Wolff (1957) have found that paper electrophoresis of the lipoproteins is of value in a number of diseases of infancy and childhood involving lipid metabolism primarily or secondarily. These authors detected abnormalities in the serum lipoproteins in gargoylism and the severe form of hypercalcaemia of infancy, conditions associated with mental defect. Using the ultra-centrifuge, Simon et al. (1954) had earlier demonstrated an increase in the level of certain low density lipoproteins in patients with mongolism, and work in this department (Stern and Lewis, 1957, 1958a) indicated that lipid metabolism is disturbed in children with mongolism and some other mentally retarded children. Paper electrophoresis was chosen as the method for a further study of the serum lipids in mental deficiency. Of particular interest was the possible relation of abnormalities in the serum lipoproteins to the disturbance responsible for the mental defect.

Recent work at this hospital (Thorpe and Baker, 1958) has suggested that schizophrenic patients tested one week after completing a course of twenty E.C.T.s do not show significantly more impairment in some psychological functions than similar patients treated with insulin coma or chlorpromazine therapies. This finding may come as a surprise to many, particularly in view of the fact that disorientation, memory loss, and confusion are frequently seen during the course of electrical treatment.

In a previous paper (Seager, 1958) I described a retrospective examination of the records of patients who had been suffering from depressive illness and who had received electroplexy, with or without an anaesthetic or relaxant drug. The results of that survey suggested that patients who received unmodified E.C.T. were in hospital for a shorter period, received fewer treatments and were more likely to remain well than those treated with modified E.C.T. Recognizing that the method of retrospective evaluation could give rise to many errors which would affect the results, I have now carried out a controlled trial of these treatments. The aim of the trial was to ascertain any difference between the results of modified and unmodified electroplexy, and if so, to find out which factor or factors were responsible for the difference.

Unstable mental defectives in an institution present handling and training difficulties out of all proportion to their number. The following is an account of an attempt to modify or control their behaviour by the use of chlorpromazine.

The authors have independently used drug-aided psychotherapeutic techniques. Some good results were being obtained but we were not entirely satisfied with existing agents. The first few applications of parenteral “Ritalin” appeared promising and prompted the work on which this paper is based.

Historical Background. The possibility of relationship between a person's birth experiences and his later reaction tendencies has long been recognized. Such recognition is expressed in the ancient Chinese saying (translated approximately), “Difficult birth, difficult child”. As early as 1794, Erasmus Darwin (4) wrote that “the association of the disagreeable sensations and actions occasioned by birth” persists throughout life and forms the basis of all later fear reactions.

In a recent paper, Parnell (1957) has criticized the Rees-Eysenck Body Index (Rees and Eysenck, 1945) on a number of grounds. He also showed that high values on the index corresponded to high values of Sheldon's ectomorphy component, while low values on the index corresponded to low values of the ectomorphy component, and high values of the endomorphy and more particularly the mesomorphy components. In this paper a brief attempt will be made to answer Parnell's criticisms and indicate why the Rees-Eysenck Body Index appears to be preferable to the Sheldon system.

Trifluoperazine (Stelazine) is a phenothiazine derivative and is 2-trifluoromethyl-10-(3′ 1″-methyl piperazinyl-4″-propyl) phenothiazine dihydrochloride. It is related to prochlorperazine, and in fact differs only in having a trifluoromethyl group in place of the latter's chlorine atom in position 2 of the nucleus. However, in laboratory studies, tests based on the inhibition of conditioned responses have indicated that this compound was 5 times as effective as prochlorperazine and 10 times as potent as chlorpromazine on a weight for weight basis.

A review of the literature which is accumulating on the so-called tranquillizing drugs shows:

1. A relatively small number of adequately controlled trials with, in general, more conservative conclusions than those of the much greater number of uncontrolled trials (Foulds, 1958).

2. Diffuseness in patient selection, with subjects often being chosen for behavioural qualities (e.g. overactivity) or general characteristics (e.g. chronicity) rather than for diagnosis.

Perivascular cysts visible to the naked eye have been described in the brain of several cases of gargoylism (Lindsay et al., 1948; Henderson et al., 1952; Naidoo, 1953). In most instances they were small, not exceeding 1 mm. in diameter and confined to the white matter of the cerebral hemispheres. The present case is remarkable for the exceptional size of the perivascular cysts which had led to gross bilateral cavitation of the thalamus and putamen.

In its classical form this peculiar disease is characterized by an irresistible compulsion to swear, together with motor tics. First recorded by Itard in 1825, it was later fully described (1885) and followed up (1899) by Gilles de la Tourette, whose name has been given to the condition. Associated with the compulsive utterances are multiple motor tics, hence Convulsive Tic is a synonym for the malady. The motor movements are more severe and widespread than those met with in simple tic, and they may involve the whole body in a violent spasm. Facial grimaces, violent jerks of the head, limbs and trunk may occur, often combined with an explosive utterance. This exclamation may consist of an unorganized sound such as a bark or a groan or a grunt. Or it may be a word—frequently of an obscene nature (coprolalia) which greatly embarrasses the patient. Other features of the condition are echolalia—the impulse to repeat sounds or words which the patient hears, and echbpraxia—the compulsion to copy the actions of others.