“Fear is more pain than is the pain it fears.”

Sir Philip Sidney.

In the opening chapter of his Body and Mind (1873) the physician and philosopher whom these lectures commemorate wisely insists that our inquiries into human faculties should begin with the elementary and proceed only later to the elucidation of the complex. “Surely,” he says, “it is time that we put seriously to ourselves the question whether the inductive method, which has proved its worth by its abundant fruitfulness wherever it has been faithfully applied, should not be as rigidly used in the investigation of mind as in the investigation of other natural phenomena. If so, we ought certainly to begin our inquiry with the observation of the simplest instances …” In the chapters which follow he applies this principle, and—or so it seems to me—provides a number of healthy correctives to much modern thinking and writing, and not least to the opinions of those who have allowed too little or assumed too much in their appraisals of the body-mind relationship. If we have for too long separated psyche and soma, past and present, organism and environment, individual and society, in our attempts to fathom Man, may not an extension of interest in a primitive emotion such as fear, in which the interdependence of all of these is manifest, have value?

It is a very great honour to occupy the Presidential Chair of the Psychiatric Section of the Royal Society of Medicine; it is one which I appreciate most highly, and thank you warmly for.

Introduction.

The Admission of Aged Psychiatric Patients to Institutions.

It has recently been pointed out (Lewis, 1946) that between the years 1907 and 1937 the number of first-attack admissions of patients of 65 years and over, into the mental hospitals of England and Wales, differs considerably from analogous American figures. In Britain, using statistics supplied by the Board of Control for England and Wales, there was a marked tendency for the incidence of this group to decline, whereas in America, using statistics from New York Mental Hospitals Board, there was a marked increase. An explanation is found in the assumption that in England large numbers of cases which would be relevant to the statistics, were looked after in other institutions or at home, whereas in America less alternative accommodation was provided. It is doubtful, had the investigation been continued up to the present date, if the statistical divergence would have been found to continue. The incidence of first-attack admissions of those over 65 has, of course, a more subtle significance than a simple admission-rate for an age-group, or even a first-admission-rate, but the present impression in British Mental Hospitals is that admission of old persons—even first-attack admissions—has increased, especially during the war years. Post (1942) demonstrated this rising incidence of aged patients by analysing the admissions to Edinburgh Royal Mental Hospital from 1904 to 1942.

Cases showing alexia which is not part of a general visual agnosia or of a speech disorder (letter or word blindness, cécité verbale pure) are uncommon and deserve careful study for a variety of reasons. The conception of word blindness as loss of visual memories due to a localized cerebral lesion (Hinshelwood, 1917) has been challenged by later investigators who aimed at a more general analysis of impairment of cerebral functions. The application of the principles of Gestalt psychology has introduced new aspects into the study of word blindness. Investigations into acquired word blindness, apart from their psychological and neuro-pathological interest, are of value for the understanding of congenital word blindness which has been found to be a condition of considerable practical importance. It was the investigation of cases of acquired word blindness which led Hinshelwood to the first full description of the congenital disability.

Amnesic aphasia has a peculiar position within the aphasic disorders, and it has always been found difficult to bring it into any aphasic scheme. The nearest to it in Head's (1926) classification of symbolic disorder is his nominal aphasia. This, however, is actually a sensory aphasia, in which the difficulty in finding words prevails; it has lost all the characteristics of the classical amnesic speech disorder. Goldstein (1926), on the other hand, while stressing the existence of the amnesic aphasia as a definite and well-circumscribed type of disorder, denies that it has anything to do with a speech defect—an opinion up to then held. According to him, it is fundamentally a defect in the thinking process in which the patients have sunk to a lower and more concrete level of behaviour. They have, according to Goldstein (1926), lost the categorical meaning and use of words; they may be able to name an object in a concrete situation, but are unable to generalize, to use the word in its class meaning. Since then this question has been critically examined by several authors (Hauptmann (1931), Isserlin (1936), von Kuenburg (1930), Lotmar (1933), Scheller (1938)) in the light of Goldstein's conception. In their conclusions, repudiating Goldstein's opinion, they reaffirmed the classical view of a basic speech disorder in the amnesic aphasia.

There have been several deaths during or after penicillin therapy for G.P.I. (Goldman, 1945; Neymann et al., 1945; Weickhardt, 1946, and Rose and Solomon, 1947), but there have been no reports of neuropathological studies. We think, therefore, that it may be of some value to describe the pathological findings in the brains of four such cases.

The therapeutic factors operative in group treatment are still partially controversial, and further investigations are necessary to clarify their nature, mode of action, and range of curative potency.

The pupils of a normal subject are generally described as equal, reacting by constriction or dilatation to various stimuli. Inequality of the pupils as an isolated finding is said to be relatively common, but impairment of the light reflex, especially in conjunction with pupillary inequality, is held to be strongly indicative, if not pathognomonic, of organic disease of the nervous system. An exception is the “tonic pupil,” for whose abnormally protracted reactions to light and accommodation an organic lesion has not yet been demonstrated. However, impairment of the light reflex is known to occur in subjects in whom there is no evidence of organic nervous disorder. These abnormalities of the light reflex have attracted little attention in this country, and are ignored almost entirely in text-books of neurology and psychiatry. Redlich (1908) made the important observation that muscular exertion might lead to dilatation of the pupil with impairment of the light reflex. Levine and Schilder (1942), in an extensive investigation of this phenomenon, concluded that muscular effort would produce dilatation and impairment of the light reflex in any pupil which initially retained its response to light, and would accentuate a pre-existing abnormality or bring out a latent tendency to impairment of the light reflex. Westphal (1907) first described the pupillary abnormality in catatonic schizophrenia to which the term “catatonic pupil” has been applied. This abnormality consists of pupillary dilatation with impairment of the light reflex, and is usually bilateral. The reactivity to light may vary from moment to moment, or from day to day; or pupillary rigidity may persist for a considerable time, with transient periods of brisk reactivity. Estimates of the frequency of the “catatonic pupil” vary remarkably—from 54 per cent. (Schilder and Parker, 1931) to 3.4 per cent. (Reichmann, 1913). Apparently a higher incidence has been found where repeated examinations have been carried out on the same subjects, but proper comparison is impossible, as the technique of examination has not been detailed by any of the authors.

The mental hospital of to-day has developed in stages from the earliest of which we have any particulars.

Progress in planning and design has been gradual, with periods during which it has been pronounced. Each period has shown an advance in the lay-out and detailed arrangement of the buildings to meet the coincident advance in methods of care and treatment of the patients.

I welcome the opportunity of presenting this short paper to the meeting, particularly as I have just returned from the United States, where I have seen something of the modern trend of psychiatry in that country.

The memorandum on the future organization of the psychiatric services, published by this Association in 1944, defines a psychiatric unit as that part of a general hospital, whether in-patients or out-patient, which is set aside for the treatment of mental disorders, with or without legal formalities.

I. The Problem.

If we have a group of letters describing how discharged post-leucotomy patients are getting on, and what they are doing (1), it is useful to be able to determine how far the traits reported can be regarded as typical of post-leucotomy patients in general, peculiar to a particular clinical class, or unique to a single patient. Information of this kind clearly helps a doctor to predict what personality traits are likely to be noticed after the operation.

Introduction.

This contribution is itself introductory to a larger subject, and is an attempt to present some physiological observations in a way that may stimulate the interest of psychologists and psychiatrists. Viewed from a biological standpoint, man is limited in his thinking and behaviour by his innate constitution, anatomically and physiologicallly. As a living, functioning individual he is much more than the mere sum of his parts, yet it is a fact that structurally he is made up of reflex arcs (receptor endorgans, afferent nerves, central nervous system, efferent nerves and effector organs). The vital functions of nutrition, respiration, circulation, excretion, reproduction, locomotion and metabolism are effected by standard types of reflexes which pervade the vertebrate kind, so that a dynamic reflexological approach to normal and abnormal human behaviour should be revealing. Man is stimulated by his total environment to respond as a complete being, and this full activity is retained as experience which modifies subsequent behaviour. That being so, the nature of integration of these reflexes and the ways in which they are influenced by experience constitute a subject very pertinent to the study of psychology and psychiatry. Something of that nature forms the material of this paper.

It is generally recognized that the capacity to grasp new ideas and learn new methods of work depends partly upon a person's intelligence and partly upon his age. It is also recognized that over-taxing a person's capacity to acquire new methods of work, or inadequate opportunities for a person to develop the capacity he possesses, are sources of dissatisfaction, mental strain, and sometimes physical complaints amongst normally healthy people. There is even reason to believe that amongst less healthy people they contribute towards disaffection and illness.

I wish to make it clear at once that for the purpose of this paper I am taking the definition of psychiatry as being synonymous with the term psychological medicine—in other words, the study of the subject as a whole.