In the present paper I do not intend to deal with those graver affections, such as apoplexy or paralysis, which frequently occur in the aged, and which depend on gross lesions of tissue. Nor shall I mention the severe and intractable neuralgias of advanced life. I desire to direct attention to a class of neuroses, which more or less inevitably attend the decline of life, and which, though they do not involve any serious catastrophe, are the cause of so much suffering that it is surprising that they should have received little or no systematic notice from medical writers. The neglect of these complaints is not merely a negative evil; for, owing to the fact that their neurotic nature is ignored, certain superficial symptoms which they present are treated as if they depended on functional disturbance of the liver, or ordinary stomach catarrh, &c., and very often with depressing remedies, which greatly aggravate the existing evil.

There is a type of social psychology which finds the explanation of man's social behaviour in a hypothetical “disposition” of his mind. This motive-complex is conceived as specialized for the function of adapting conduct to social life, and as being in itself relatively closely integrated, developing and functioning as a whole. Of this hypothetical “gregarious instinct” McDougall goes so far as to say: “For it is highly probable that instinctive dispositions are Mendelian units” (Journ of Abn. Psych, and Soc. Psych., vol. xvi, p. 316). This plainly suggests that the unity of the social disposition (its existence as a discrete factor in development) is to be regarded as antedating experience—that it is an ultimate datum for psychology not susceptible to analysis, and is not a derivative of any other known motive such as “love,” “fear,” or “hope of reward.” This “instinct” interpretation of social behaviour has been criticized on many grounds (as unfruitful for psychology and incompatible with biological fact); but of course the demonstration of a Mendelian transmission of the social disposition would compel us to regard it as an element of character. Our conception of mental development and of the “socialization” of the individual, of the relative significance of upbringing as compared with organic endowment and our whole psycho-pathology depend upon our acceptance or rejection of McDougall's view. If he is right in regard to the germinal “unit” determination of the social disposition, criminological studies should offer verification. I propose, therefore, to consider how far we are justified in regarding moral insanity and moral imbecility as true “morbid entities.”

The great progress which medicine in general has made during recent years, must in considerable part be ascribed to the anatomical direction it has assumed. The study of pathological anatomy has entirely changed the character of medical science, which, instead of a chaotic medly of unfounded theories and ingenious hypotheses, the fruits of speculation, is now a philosophic system resting on a firm foundation of facts with mutual and definite relations. To such an extent has the pathological investigation of disease been carried, that, in the ordinary maladies which attack the body, the instances are now exceptional where we cannot demonstrate certain gross, palpable changes of structure having an invariable causal connection with functional disturbance. By bringing diagnostics to our aid, we can also in many cases predict with confidence and precision the nature and extent of the lesion which will be found after death. But the triumph does not cease here. In conjunction with chemistry and the microscope, pathological anatomy has passed from the gross alterations of organs, and succeeded in elucidating the processes and changes which take place in their ultimate elements; and Virchow, bringing to the subject all the zeal and instinct of genius, has given us an insight into the arcana of cell-life, and laid down the comprehensive generalisation as the basis of a new pathology, that the cell is the ultimate agent by which, both in health and disease, structural and functional alterations are effected. All the practical departments of the healing art have participated more or less in this progress. Medicine proper, or that branch which restricts itself to the study of internal diseases, has separated itself more and more from dynamics, and found a natural explanation of its symptomatology in anterior changes of structure; while surgery and mid-wifery, with their outbranching specialities, are daily becoming more anatomical in character.

In psychiatry, generalization is a process which requires careful handling. It must be firmly rooted in everyday experience of the practical empiricism which gets results, and must be free, as far as possible, from the numerous fallacies which have brought “armchair” philosophizing into disrepute. These are formidable requirements, but fortunately one way of meeting them lies ready to hand. There are doubtless many others apparent to more fertile minds, but the one with which this paper deals rests on the fact that a patient who has been successfully treated by a psychiatrist behaves, when well again, in a different manner from that which he displayed when ill. He is cheerful, not depressed, relaxed, instead of being tense; realistic and socially enterprising as opposed to being autistic. If the term “Behaviour” is used in a sufficiently wide sense, it can cover the great majority of psychiatric phenomena without losing its cardinal virtue for the present purpose, namely that behaviour can be observed and its manifestations measured with considerable accuracy. The products of observation can be handled statistically, thereby avoiding armchair theorizing. Admittedly the interpretation of statistically derived findings presents some difficulty, but this is not insuperable. It is usually easier than the process of generalizing from observed data without the benefit of statistical pre-digestion.

When I accepted the great honour of giving the Maudsley Lecture this year, I was instructed that my subject should be one of popular interest. The theme of “Education in Medicine” was chosen with some trepidation, not so much on account of any lack it might have of intrinsic interest, but because its elaboration might lead me to express views not entirely in harmony with popular opinion. “Education in medicine” rather than “medical education”, because I had it in mind to discuss the kind of instruction which, if within his reach, would enable the layman to recognize and appreciate some of the principles on which the practice of medicine is based and pursued. And my choice was determined by the conviction, which must be generally shared, that the practice of medicine is much handicapped by a want of understanding, and therefore of sympathy and co-operation, on the part of the public—a want of understanding, the causes of which might be explored with advantage to both parties concerned in it.

In the past head injuries have been of comparatively little concern to the psychiatrist. As judged from statistics of admission to mental hospitals they are a small problem. Mapother (1937), for example, who took a very broad view of the causal connection found in L.C.C. mental hospitials—3 per thousand in observation wards, 4 per thousand in psychiatric O.P. depts. in general hospitals, 7 per thousand of the admissions attributable to head injuries. The increasing interest that psychiatrists take in head injuries at present is mainly due to the increasing amount of extramural work that they are being called on to do. In general hospital and outpatient practice they are bound to encounter a considerable number of problems connected with head injuries, both in the acute and in the later stages. The psychiatrists and neuro-psychiatrists in the Services have probably had this experience first, but when adequate provision of psychiatric service becomes available in the general hospitals, many cases will come into the orbit of psychiatrists which hitherto have been “disposed of” without much regard for their mental aspect.

The way in which schizophrenics react to physical illness and injury is a problem worthy of study, especially at the present time when schizophrenia is being so widely treated by methods which bring about profound changes of the physical state. Although schizophrenics, recent and chronic, are very susceptible to physical illness and form a considerable part of the sick population of the average mental hospital, this question has not attracted a great measure of attention. A survey of the schizophrenic population of a mental hospital suggests that there is an apparent lack of specific psychotic reactions to physical illness, so that it would seem as if schizophrenics react to physical illness either in a normal way or more commonly with indifference. It is true that certain paranoid patients include complaints of physical disturbances in their systems of delusions, but as a rule, even in these cases, there is no specific reaction to physical illness, which like other experiences enters into the world of imagination in which the patient exists.

It has been suggested to me by a professional friend, in whose judgment I place much confidence, that I shall aid in demonstrating the value of night nursing in the moral treatment of the insane, and perhaps remove prejudices which yet exist against its use, by laying before the members of this Association a record of my experience of the system at the Sussex Asylum during the first half of this year.

From October, 1947, to October, 1952, we have had the opportunity of performing prefrontal leucotomy on 339 patients at the Neurosurgical Clinic in Belgrade. As this operation is of importance in the treatment of mental disease we consider it necessary to report our experiences and our results.

In every civilised community, however imperfectly the wish may be fulfilled, the desire is to do equal justice to all; to up hold the law as a terror to evil-doers, and the protector of the innocent.

There is a very general impression among members of the medical profession abroad that it is only by the free use of stupifying drugs that British alienists are able to dispense with the use of mechanical appliances in the management of the insane. It cannot be gainsaid that, by the use of toxic remedies, noisy and violent patients may be as effectually controlled for the time being as by any species of mechanical appliance; nor can it be denied that in many of our asylums narcotics and sedatives are employed in such doses, so continuously, arid for such purposes as to justify the appellation of “chemical restraint.” But there are no facts to bear out the assumption that it is by excessive drugging we are enabled to avoid the use of restraining apparatus in our asylums. On the contrary, there is incontrovertible evidence to show that in foreign asylums where mechanical restraint is extensively practised, chemical restraint is likewise employed to an extent not thought of in this country. Dr. Wilbur∗ has been at pains to collect statistics for purposes of comparing the relative extent to which mechanical and chemical restraint is carried in British and American asylums. The result of his investigation clearly shows that in British asylums and in the few American asylums conducted on non-restraint principles, chemical restraint is not the substitute or alternative for mechanical restraint, but that, on the contrary, the general rule seems to be: the more mechanical restraint, the more chemical restraint.

In a disease with so widespread a seat as general paresis, in which the cerebral syphilitic changes are local manifestations of a generalized infection, it is only reasonable that an attempt should be made to correlate the cerebral changes with those found in other organs in the same body.