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.

There has been much discussion about the possible occurrence of reversible and irreversible histological changes in the brain following the convulsive treatment of mental disorder. Most investigations have been carried out either on experimental animals—with results not easily comparable to man—or in deceased patients in whom the picture is usually obscured by the presence of complications. The various causes of death following convulsive treatment have recently been reviewed by Maclay (1953).

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.

The impulse to attempt this study arose from difficulties encountered in the process of trying to demonstrate the efficacy or inadequacy of various methods of psychiatric treatment (Monro, 1950; and Monro and Conitzer, 1950). The problem which arose was that of matching groups, whose composition necessitated a struggle with diagnostic and prognostic criteria difficult to define and still more difficult to secure agreement about. The chief trouble derived from the fact that the systems of classification in normal psychiatric use had their roots in the past, when the cases were dealt with at a more advanced stage, or were of a more serious nature, than many which are today seen in out-patient clinics and mental hospitals. In the search for a more adequate system of classifying recent and therapeutically promising cases, the work of Cattell (1946) suggested a possible method of advance. It seemed sound to hope that the application of modern psychological techniques to psychiatric problems would be as useful as past applications of the principles of physiology and pathology to clinical medicine.

The purpose of this paper is to investigate one of the basic assumptions of the Szondi test, namely, that in selecting pictures in the test subjects tend to assign consistent meanings to the pictures, although these meanings are not explicitly stated. In the following experiments, this assumption was tested by obtaining explicit reactions to the pictures in the form of identifications, using two different experimental methods. Similar studies have been made by Klopfer and Borstelmann (1950), Rabin (1950a), Fosberg (1951), Davis and Raimy (1952), and by Dudek and Patterson (1952). In all these investigations, American subjects with some experience of psychology or psychiatry were used. The most extensive work was done by Klopfer and Borstelmann, who used a sample of American psychology students, and suggested that their methods might be employed on “other segments of the population”. In the following experiments, their methods have been largely adopted for English subjects, of varying ages and occupations, including students.

In 1947 the Board of Control published its report on the results of 1,000 leucotomies, citing therein a mortality of 6 per cent. Five years later Dr. W. S. Maclay, in his Presidential Address to the Section of Psychiatry of the Royal Society of Medicine, referred to 180 deaths during the interval, a mortality of approximately 2 per cent. Although this is a striking improvement there is still cause for apprehension, for by far the greatest proportion of fatalities arise out of haemorrhage. The second causative factor in fatal issues is infection. Something must be done to put psycho-surgery on a yet safer basis.

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.

If the standards of psychotherapy approximated to those in vogue in the field of organic medicine a lecture on the indications for psycho-analysis would be a comparatively brief and possibly tedious affair. Since, however, there is no uniform diagnosis of mental disorders, no exact account of the rationale of psycho-analytic treatment and no assented list of the modifications of treatment required in different forms of disorder, it is obvious that before we can usefully discuss indications for psycho-analysis or in other words the scope of psychoanalytic treatment we must arrive at a certain amount of agreement regarding the diagnosis and prognosis of mental disorders and the nature of psychoanalytic therapy.

In view of the importance of prenatal pathology at the present time, a useful purpose may be served by attempting to review the peculiar weaknesses and strengths of the developing nervous system. As a result of personal inclinations, this presentation of the various problems involved will have a structural bias; the subject would, no doubt, be approached very differently by a physiologist, for instance, or by a biochemist. Nevertheless we should all be describing different aspects of the same series of phenomena, aiming at an understanding of the events which must occur before the central nervous system can function.

Hemispherectomy in man (ablation of the cortex, the underlying white matter and nucleus lentiformis) was performed first by Dandy (1928, 1933), later by Gardner (1939) and a few others, on adult patients suffering from large infiltrating tumours of the subdominant hemisphere, with one exception (Zollinger, 1935). It was carried out by McKenzie (1939) apparently on a patient suffering from infantile hemiplegia with epilepsy. Krynauw (1950a, b) began systematic work of this nature on cases of infantile hemiplegia with epilepsy and personality disturbances. Apart from its therapeutic value, in carefully selected infantile hemiplegics, in the hope of lessening or curing epilepsy, and exerting a beneficial influence on behaviour and further mental development, the comparatively small loss of functions after removal of one hemisphere is most remarkable.

We have at present no reliable method for indicating the correct sequence of treatment in neurotic cases showing a manifold symptomatology. In such cases much time may be lost through attacking superficial rather than basic conflicts. It would therefore be an undoubted advantage to possess a means of indicating objectively and by experiment which problems are fundamental, and to the resolution of which treatment should be first directed.

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.