One has to admit that the treatment of the mentally ill by psychological methods only leaves something to be desired, for even in the neuroses the long term results of psychotherapy are at times disappointing. Shorter methods of treatment, more economical of time and surer of outcome are constantly sought and, of course, there remains the very considerable problem of how to treat the not over-intelligent neurotic who can never hope to achieve profound self knowledge or insight.

It is now several years since acetylcholine was first administered intramuscularly in the symptomatic treatment of anxiety, on the theory that anxiety was sympathicotonic in nature and could be counteracted by the vagotonic action of acetylcholine. Unfortunately decomposition of acetylcholine is so rapid that there is little time for this action to be effective, and the majority of investigators believe that it has no effect, or at least a momentary one, when given either subcutaneously or intramuscularly. Maxwell Jones (1936) used carbachol, a drug with a similar but more prolonged action than acetylcholine to treat six patients with anxiety neurosis. He was able to report relief from the psychic and somatic symptoms of anxiety in all cases but unfortunately, following withdrawal of the drug, they tended to relapse. An entirely different rationale led Tomasson (1936) to claim both alleviation and shortening of the duration of attacks of mania in manic depressive psychotics using a combined ephedrine and acetylcholine treatment.

A geriatric unit containing 200 female and 110 male beds was fully opened at this hospital in March, 1953. There were then resident in hospital 226 females over 70, and 165 males over 65. The aim of this paper is to discuss the mental and physical health of the inmates and assess their medical and nursing requirements. It is hoped that this information will be of value to those intending to open similar units.

This hospital is unique in having a catchment area of over 1,000,000 and only 2,000 mental beds. Three hundred of these are taken by mental defectives, and 500 are over 65 years of age. There is a severe bed shortage with resulting delay in admission of elderly patients from the observation wards. The large initial death rate in the month following notification occurs mainly outside this hospital, and many patients are discharged from the observation wards without reaching the hospital. Admissions are restricted to those with severe conduct disorder. Thus the death rate and discharge rate will be lower than hospitals with a more fortunate bed-population ratio.

The Concept of the Body Image and the Perception of the Human Body

The consideration of our awareness of our own bodies ceased to be wholly a philosophical problem when Pick (1908) and Head and Holmes (1911), having observed neurological disturbances of body awareness, first suggested the concept of a Body Image or Body Schema. The concept, has in its slow growth, become at times confused and has always resisted satisfactory definition. Pick himself made no attempt to define it, while for Head and Holmes it was a “postural model of the body” being constantly built up and changed by every new posture and movement and forming a “plastic schema” which was “the fundamental standard against which all postural changes are measured“. Schilder (1935) greatly enriched the concept by emphasizing not only its physiological and neuropathological basis but its psychological aspect. He defined it thus: “The image of the human body means the picture of our own body which we form in our mind, that is to say the way in which the body appears to ourselves.” This was a comprehensive “body image”; more than a perception or mere representation and including even Head and Holmes's “Body Schema“. The Body Schema concept has been more recently defined by Clifford Scott (1948) as “that conscious or unconscious integration of sensations, perceptions, conceptions, affects, memories or images of the body from the surface to its depths and from its surfaces to the limits of space and time”.

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.

The speakers for this morning's discussion were asked to be practical, to limit themselves to giving an account of the essential uses of the EEG technique for clinical psychiatry, and to avoid, as far as possible, the theoretical and speculative aspects of the subject. No doubt the time has come for an attempt at re-appraisal. In the last 10 years EEG departments have been developed in most of the larger mental hospitals and nearly every psychiatric centre or group, be it mental hospital, out-patient department or child guidance clinic has access to an EEG department and refers patients for examination in increasing numbers.

The first recorded attempt to use carbon dioxide inhalation systematically as a form of psychiatric treatment was by Lovenhart et al. (1929). The subjects were catatonic schizophrenics and such modification as occurred was fleeting in nature.

In 1943 Meduna began to use carbon dioxide inhalation in the treatment of the neuroses and his efforts were described in a series of papers and developed in a monograph (1950). This contains a full description of the physiological and pharmacological effects of carbon dioxide upon nervous function and the technique of administration is described as are also the results in 100 patients. These results are taken as giving some support to a neurophysiological theory of the neuroses based on homeostatic and cybernetic considerations. Efforts were made to minimize the effects of “suggestion” and, although the difficulties are acknowledged, the following passage suggests that the author was reasonably satisfied with his precautions.

Two observations made on the post-leucotomy patient inspired the investigation to be reported in this paper. They are, first, that the post-leucotomy patient seems unable to deal with two things at once. Both Ackerly (1935) and Brickner (1939) have referred to this deficit. The second observation was that there was apparently lesser vitality of imagery after operation. A photographer in Pippard's study (1955) who had had, as he said, a “photographic memory”, could no longer connect people's faces with photographs of them he had taken in the past. A 35 year old schoolteacher in the same study completely lost her visual imagery after operation, and Brain (1954) has reported a similar deficit in two cases. Zangwill and Humphrey's report (1951) of cessation of dreaming in some patients after brain injury is possibly related to this deficit. Petrie (1952) found an increase in reversals, especially willed reversals on the Necker Cube after operation, and Gordon (1950) has presented findings showing that the control of fluctuation was significantly related to less vivid and controlled imagery.

The investigation reported here was designed to examine further these two post-leucotomy deficits, and to see if they were related in any way.

A number of studies have shown that the incidence of schizophrenic illness (as measured by first admissions to mental hospitals) is high in the central areas of large cities and diminishes progressively towards the suburbs (Fans and Dunham, 1939; Dunham, 1947; Hare, 1956). Two main hypotheses have been advanced to account for this distribution. The first, the “breeder” hypothesis, is that social factors in the central areas are causal for schizophrenia and the particular factor most likely to be responsible is that loosely called “social isolation”. The second, the “attraction” hypothesis, is that the social disorganization or anonymity characteristic of the central areas attracts unstable and schizoid persons, either because such persons are unable to maintain themselves in better areas or because they wish to avoid the intimate personal relations of family life.

Marquis (1948) has suggested that psychological research can be carried on at three fairly distinct levels: isolated experiments on particular topics, programmes of work on general topics, and long-term investigations of whole areas. This report is intended as a contribution to the third level, i.e. the level of policy design, and makes recommendations about the general nature and scope of psychological research on maturity and old age. The advantages of a generally accepted but informal research policy are clear: basic problems are located and adequate methods are developed for tackling them, theoretical systems become strongly linked with practical issues to the benefit of both, knowledge is more readily communicated because research workers have a common frame of reference, research findings become progressively more comprehensive, detailed, accurate and meaningful, and so on. Possible disadvantages are that originality may be curtailed and work may be duplicated, but it is doubtful whether the former is a real danger or the latter a real disadvantage. This report is not intended to specify particular research projects or programmes—this could be done only after discussion between members of research teams, their sponsors and advisers—the final choice of project depends very much on the interests and abilities of the team members and on the human ecology of the area in which they are working.

The present paper is a continuation of work previously carried out and is an attempt to define more accurately the conditions under which the rotation effect can be induced in normal subjects.