Too deeply moved to search for originality of expression, I hope that you will allow me to fall back on some of the well-worn phrases in acknowledging the honour conferred on me when I was chosen to be this year's Maudsley lecturer. My reaction was summarized in my reply to the notice which reached me in May, 1957. I wrote: “I accept amidst an understandable struggle between pride and humility. The name ‘Maudsley Lecture’ has an almost hallowed connotation among my professional contemporaries, and this invitation comes to me as a sort of crowning acme of my career.” I am delighted to share my laurels with the Johns Hopkins University, which I joined exactly thirty years ago at the call of Adolf Meyer, whose gigantic contributions to psychiatric theory and practice were attested by the Royal Medico-Psychological Association when he was nominated to be the fourteenth Maudsley Lecturer in 1933. In going over the list of my illustrious predecessors in this series of addresses, beginning with Sir James Crichton Browne and Sir Frederick Mott, I find that I am the second United States psychiatrist to receive so great a distinction. I am certain that I voice the sentiments of my University when I say that it considers this event as an added and happily displayed feather in its richly decorated cap. The Johns Hopkins University has recognized the growing importance of child psychiatry by creating a full professorship in this discipline, and I am pleased to be the symbol of this recognition. And now your Association has indicated its desire that I speak as a child psychiatrist “as this specialty has not been covered in a Maudsley Lecture before”. To have been selected as the first spokesman for child psychiatry in this group is a thrilling experience laden with heavy responsibilities.

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.

In a recent book, Sargant (1957) has discussed many examples of human beings who, after brief or prolonged mental tension, including terror, underwent a sort of reactive collapse into a state which, in its extreme form, was one of stupor. Sargant interpreted these reactions in terms of a physiology derived from Pavlov, particular emphasis being laid on “transmarginal inhibition“—a variety of the “internal inhibition”, or “hypnosis” which Pavlov identified with sleep, and which was manifested by motor inertia and unresponsiveness to stimuli. Pavlov's dogs exhibited internal inhibition in response to monotonous stimulation of any kind (including repeated electric shocks); repeated non-reinforcement, disappointment, or non-fulfilment of the dog's expectations; delay in reinforcement; and, in experienced dogs, in response to being placed in the experimental situation (or having the stimulating electrode attached to the leg in the case of those given electric shocks).

Controversy has raged for over half a century as to whether schizophrenia, the most severe of all mental illnesses, could have an organic basis or whether its origin lay strictly in the psyche. Over the years, physiologists have probed into almost every aspect of the soma in the quest for some abnormality which would account for the schizophrenic syndrome. Many possibilities have been considered, investigated to a degree and then abandoned when definitive answers were not forthcoming. A dominant approach throughout has been the search for some psychotoxic material circulating in schizophrenic body fluids. Activity has been spurred by the recurrent recognition that chemical agents such as the ergot alkaloids, mescaline, bulbocapnine and lysergic acid diethylamide (LSD-25), could induce in normal persons transient mental disturbances similar to those seen in schizophrenia.

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)).

The object of the experiment to be described in this paper, was to find out if it was possible to develop a systematic experimental investigation of paranoid delusions.

Dementia paralytica is a declining disease. Deaths due to it in England and Wales were first recorded by the Registrar General in 1901 and since that year, when the number was 2,272, the annual figure has fallen steadily until in 1957 it was only 68. Moreover, there is evidence (adduced below) that not more than a small part of this decline can be attributed to improvements in medical treatment. The fear that there might be a recrudescence of dementia paralytica as a result of the spread of syphilis during the second world war has not so far been realized and it seems likely that what is now, in Great Britain at all events, an obsolescent disease will soon become a rarity. Yet there are many unsolved problems in its history. We do not know, for example, why the alleged references to this striking disease were so few and so inadequate until the third decade of the nineteenth century. We do not know why its recognition in many countries was so tardy in spite of the clear description given by the French alienists. Nor do we know why the disease, which at the start of the nineteenth century seems to have been predominantly one of males, has gradually—and at different rates in different countries—become much more evenly distributed between the sexes.

Fashion is more deep-rooted than contemporary custom will allow, and the current enthusiasm for drug treatment in psychiatry is no evanescent fad. The Greeks made good use of the pharmacopœia, prescribing borage, buglosse, marigold, polypodie and epithyme for melancholy, more specifically recommending wormwood, centaury and pennyroll for the hypochondriac malady. Burton (a) discussing black hellebor, relates that its virtues were extolled by Galen, Pliny and Coelius Aurelianus, the mentally afflicted being sent to the Anticyrae, or to Phocis in Achaia to be purged, the plant growing there in abundance. Burton (b) describes how the Melangoga, or melancholy purging medicines, were classified as simple or compound, purging upwards or downwards. Asarum, brassivola, laurel, scilla, white hellebor, and antimony purged upwards, whereas polypodie, epithyme, black hellebor, lapis lazuli and aloes purged downwards. Sceptics throve then, no doubt, as they do now. Meryon (1861) mentions Asclepiades—dismissed by Pliny as an impudent quack, who contended that drugs injured the stomach and induced complaints more dangerous than those which they were intended to cure.

This paper is an attempt to clarify and give content to the concept of inadequacy of the personality, for the concept has gained considerable currency in psychiatry as a hypothesis to account for difficultieg encountered in diagnosis, prognosis and treatment. Before the theory can be evaluated, it should be stated in a reasonably precise form. This enquiry starts from a very general statement about the idea of inadequacy as usually encountered in psychiatric practice, and proceeds towards a formulation in more exact terms.

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.

The problems of diagnosis, pathogenesis, aetiology and successful treatment of the idiopathic schizophrenias is one of the most urgent and formidable ones which psychiatry has still to tackle. It is most urgent because of the large number of sufferers struck by the disease, made unfit for a successful life at an early age, and the distress imposed on them and their relatives. It is most formidable because our essential knowledge of the nature of this disease, or possibly group of diseases, is scanty and disorderly and opinions are conflicting and contradictory. This unsatisfactory state is made worse by the fact that there is quite an amount of disagreement on diagnosis, so that often the findings of different workers do not refer to comparable groups of patients (and conditions in which they are examined) which must add to the confusion, particularly when metabolic examinations are carried out. Too often “marginal psychoses“, and also not rarely, paranoid hallucinatory states with and without changes of the personality are called “schizophrenia”. The last-named states are not infrequently schizophrenoid reactions (or reactions of a schizoid person) to psychogenic causes or to potentially diagnosable physical disorders. On close clinical examination one would also find that the symptomatology of such cases is not that of idiopathic schizophrenia. In the “classical” schizophrenias of Kraepelin, Bleuler and Kleist, despite some discrepancies, the typical para-functions of feeling, willing, thinking and activity, usually accompanied by hallucinations, mainly auditory, and paranoid delusions are present and also a disturbance of the albumin/globulin ratio in C.S.F. and serum. In the absence of this mental and physical symptomatology the diagnosis of idiopathic schizophrenia should not be made (Fleischhacker et al. (7, 8)).

For many years, schizophrenic thought disorder has been regarded as being due to an abnormality of concept formation of some sort. However, there has not been general agreement about the nature of this abnormality. Kurt Goldstein and his followers (9, 32, 33) have argued that schizophrenics are abnormally “concrete”. That is to say, they are unable to perform inductive reasoning, since they are unable to make an abstract generalization. Norman Cameron (11, 12, 13, 14, 15, 16, 17, 18, 19) on the other hand argues that in one sense at least, schizophrenic concepts are over-generalized. He believes that the concepts formed by schizophrenics are “over-inclusive”. They are unable to maintain the normal conceptual boundaries, and incorporate into their concept elements (some of them personal) which are merely associated with the concept, but are not an essential part of it. This makes their thinking both over-general, and less precise than normal. A large number of studies have been carried out to test both these hypotheses.

In Norway, the refugee problem has not been quantitatively significant. On the other hand, we have many examples to show that refugee work and interest for the fate of refugees has had an important position in the awareness and interest of the Norwegian people. The fact that the Nobel peace prize has twice been awarded to the High Commissioner for refugee organizations also speaks for itself. After the Russian revolution and its suppression in 1905 a small wave of emigrants came to Norway, and likewise after the 1917 revolution. Moreover we note a very limited and controlled immigration of victims of Nazi oppression from Germany and the occupied territories until World War II. After the war Norway was faced with a series of problems in connection with the refugees. In the first place it was a question of repatriation of Norwegian prisoners in Germany and refugees in Sweden, there were the forced evacuees from Finmark to be sent home, and then, last but not least, all the foreigners who had involuntarily landed in Norway during the war. Of these 140,000 were “displaced persons“. These had been brought to the country by the Germans either as civil workers or forced labourers in “Organization Todt”, “Organization Speer” or as prisoners of war, mainly Serbs (Jugoslavs), Russians and Poles. According to a list published in the annual report of the Ministry of Labour for 1947 (1948) the following figures are given:

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.

In the April, 1952 issue of this journal, Osmond and Smythies (47) suggested that schizophrenia might be caused by a defect in adrenaline metabolism. They called this hypothetical adrenaline derivative “M-substance” because they endowed it with mescaline-like psychotomimetic qualities but with an effective potency nearer that of adrenaline or even the hugely powerful LSD-25. They showed that mescaline and adrenaline were sufficiently alike chemically for such an intermediate to be at least imaginable. In addition, they emphasized that the mescaline experience and the more acute and dramatic forms of schizophrenia have many similarities. They hoped that researchers would hunt diligently for our M-substance.

There is very little experimental evidence about the combined effects of alcohol and phenobarbitone, administered at or about the same time. Similarities in their actions suggest that the effects of the drugs are likely at least to summate in some respects (for example, in depressing the respiratory centre); and there are experimental and forensic observations which suggest that death has sometimes occurred after a dose of ethanol and phenobarbitone, neither of which would have been fatal by itself (Jetter and Maclean, 1943; Fisher, Walker and Plummer, 1948). Phenobarbitone and other barbiturates are widely prescribed (Dunlop, Henderson and Inch, 1952), usually without reference to the habitual alcohol consumption of the patient, and potentiation as well as summation has been reported to occur between some barbiturates and alcohol (Rachek, 1944; Sandberg, 1950).

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.

It would probably be true to say that the present position in the psychiatric treatment of neurotic disorders is characterized by the following features. (1) With the exception of electroshock, the only method of treatment at all widely used is psychotherapy. (2) In practically all its manifestations, psychotherapy is based on Freudian theories. (3) With the exception of intelligence testing, psychological contributions consist almost entirely in the administration and interpretation of projective tests, usually along psycho-analytic lines. I have argued in the past, and quoted numerous experiments in support of these arguments, that (1) there is little evidence for the practical efficacy of psychotherapy, whether strictly Freudian or “eclectic” (8, 17); (2) that Freudian theories are outside the realm of science because of their failure to be consistent, or to generate testable deductions (10); and (3), that projective tests are so unreliable and lacking in validity that their use, except in research, cannot be defended (16). I shall not here argue these points again; the evidence on which these views are based is quite strong, and is growing in strength every year. I shall instead try to make a somewhat more constructive contribution by discussing an alternative theory of neurosis, an alternative method of treatment, and an alternative way of using the knowledge and competence of psychologists in the attempted cure of neurotic disorders. It need hardly be emphasized that the brief time at my disposal will make it inevitable that what I have to say will sound much more dogmatic than I would like it to be; I have to ask your indulgence in this respect, and request you to bear in mind all the obvious qualifying clauses which, if included in this paper, would swell it to three times its present size.

A recent court case (16) exposed many of the problems that confront the psychiatrist called upon to perform electroplexy.

In particular it revealed that in 1957, nearly 20 years after E.C.T. had first been used for the treatment of mental disorder, no uniform technique had yet been evolved. The medical witnesses were unable to agree on the use of muscle relaxants or mechanical restraint, but were agreed that there were certain risks attendant upon the use of electroplexy, especially the risk of fractures and the risk to life. It was argued that had the plaintiff received a relaxant drug he might not have sustained bilateral acetabular fractures, but might have suffered an even worse disaster, namely death.

Investigation of the urinary excretion of indoles in psychotic illnesses has a certain historical precedent. Thus Townsend (1905) and Bruce (1906) reported excess of indican in the urine of melancholic patients. Bruce correlated this finding with the recognized tendency to constipation in depressives and treated his patients with enemata. Ross (1913) reported that schizophrenic subjects excreted an excess of indole-acetic acid in the urine. De Jong (1945) reported the experimental induction of catalepsy in cats by the intravenous administration of indolethylamine and noted in his monograph that this substance, if perfused in vitro through the liver, is converted to indole-acetic acid. Buscaino (1952) reported finding abnormal amounts of primary and secondary amines in the urine of schizophrenics. More recently Riegelhaupt (1956, 1958) has reported an excess of tryptophan metabolites in schizophrenic urine while McGeer and co-workers (1957) have reported a difference in the excretion of aromatic substances as between normals and schizophrenics. Though these authors do not make the point clear, yet in fact indoles come under the general heading of aromatic substances.