I am grateful to those who have included me in the honourable company of Maudsley Lecturers. When you invite a speaker from outside psychiatry, I think you hope to find one who will speak from his own central interest and experience in a way which will illuminate your own. After some inner debate, I decided that I would try to justify that expectation, even though my experience may seem remote from yours. I hope none the less that what I have to say may have some relevance to some of the sciences on which you rely, perhaps even to your profession.

“The great majority of physicians, including our own specialty, have written off frontal lobe surgery as a therapeutic weapon for any illness short of chronic major psychosis.”

Community surveys abroad have shown that there is a high prevalence of serious mental illness in old age, much of which is not treated in hospital (Gruenberg, 1961; Nielsen, 1963). Most community surveys of the aged in this country have, however, been concerned chiefly with general medical and social problems (Sheldon, 1948; Simonds and Stewart, 1954), or have formed part of whole-population studies and recorded only the most severe kinds of mental disturbance in old age (Mayer-Gross, 1948). An exception is the study of a Scottish rural practice by Primrose (1962).

The literature of the psychological effects of brain injury is extensive and disconnected. It abounds in inadequate definitions, incompatible theories and disagreements as to appropriate methods of investigation. This situation results partly from the variety of disciplines which guide different investigators; but it results too from the great logical difficulties encountered by anybody who seeks to throw light on normal intelligent behaviour by studying the effects of cerebral lesions. Some have even argued that such attempts are always unprofitable (47, 77).

This paper describes the social and clinical progress of a group of male schizophrenic patients who left London mental hospitals during 1959 and were followed up for one year. The study was designed to test specific hypotheses concerning the association between family relationships and the course of the patient's illness (Brown et al., 1962).

The proven effectiveness of electroconvulsive therapy (E.C.T.) and antidepressant drugs has lately led to a resurgence of interest in the treatment of depressive states. Amongst the principal problems currently confronting the clinician, the following would seem to be particularly pertinent: should E.C.T. be used in preference to drugs or vice versa? Which drug is to be preferred? Can drug response be predicted? How long should drugs be given? When are drugs contra-indicated? Given in maintenance dosage after a depressive episode, do antidepressants lower the rate of relapse? This paper, the third report on an investigation of the effectiveness of amitriptyline (‘Tryptizol’, ‘Elavil’, ‘Tryptanol’) and imipramine (‘Tofranil’) in depressive states, sets out to answer the above questions in the light of the results that were obtained.

Introduction

The concept of hypochondriasis, and particularly its nosological position, is far from clear, and there is still a great deal of controversy as to whether or not there exists a condition of primary or essential hypochondriasis. Many of the historical and theoretical ramifications are reviewed in another paper (Kenyon, 1964). The object of the present paper is to give an account of the clinical findings in a large series of patients in order to evaluate some of the hypotheses put forward in the literature, and especially to determine if there is sufficient evidence to delineate a separate group suffering from primary hypochondriasis only. There is a dearth of well-documented case series published, although studies based on the investigation of a group of patients have been made by Gillespie (1928, 1929), Brown (1936), Katzenelbogen (1942), Alarcon (1956), Shirvaikar (1957), Greer (1961) and Ladee (1961). However, none of these attempt any sort of comparison with a “control” series, as is done in the present investigation, nor in most cases are numbers sufficiently large for drawing valid conclusions.

Nearly everyone here, I imagine, has either been present at or has read the splendid Maudsley Lecture delivered in 1958 by Professor Leo Kanner (1). In this Lecture Kanner reviewed the various interests, or, as he called them, the loosely scattered segments which by their eventual convergence and fusion resulted in the emergence, between thirty and forty years ago, of child psychiatry. He caused them to pass before our eyes in a vivid and colourful procession—psychiatry, mental deficiency, education, criminology, psychology, psycho-analysis, the child guidance clinics, with paediatrics given a place of its own, though not allowed to march in the procession itself. Now, I have been asked to take up one or two of these segments for closer examination, and give some account of their contents and development during the pre-historic period before they began to converge towards their final synthesis. In so far as I am able to do this, my account will be merely factual; I must leave it to you who are engaged in this field of work to assess the relevance of the material which I am presenting.

Speech has been called a socio-economic device for saving effort in the attainment of objectives (Whitehorn and Zipf, 1943). One of its earliest and most fundamental purposes is to orientate the individual within the community. This socializing effect operates early in childhood, and in a phylogenetic sense it was perhaps one of the greatest factors in the origin of speech in primitive man. As maturity is slowly achieved in the individual as in the genus, the use of language becomes inextricably interwoven within the warp and woof of the organism, as exemplified not only by thinking processes, but also by the complicated structure of personality. The development of speech during the pre-hominoid stage synchronizes with the gradual elaboration of communal life: with cries and calls serving as a “sound-tool”: and with the beginnings of delegation of labour. Thus language is primarily a vocal actualization of the tendency to see reality symbolically (Sapir). The same is true ontogenetically. As the child gradually acquires speech, the organization of his thinking slowly changes; it evolves by intricate steps from ego-centric to socialized activity; and as he begins more and more to employ pronouns of the second and third person, he also utters fewer “action words”. We readily agree with Fillmore Sanford (1942) that “there are many indications that language is a vehicle of personality as well as of thought, for when a person speaks, he tells us not only about the world, but also, through both form and content, about himself”. The same author quoted Ben Jonson: “Language most showeth a man; speak that I may see thee.”

Over the last few decades, social psychiatry has demonstrated correlations between mental illness and certain broad social categories. At the same time clinical, genetic and psychological studies have continued their traditional interest in the illness of the individual. The divergence of these two approaches has left relatively unmapped a large area which is of considerable psychiatric interest; despite much descriptive work, very little has been clearly established (outside genetics) concerning mental illness in the small, closely-integrated group, of which the prime example in our culture is the family. Out understanding of how personal and social factors jointly contribute to mental ill-health might well be furthered by studies in this field.

Roth and Rosie (1953) discussed the beneficial effect of E.C.T. in a wide range of psychoses complicated by clouding of consciousness, including syndromes of frankly organic origin. The treatment has been used effectively for psychotic symptoms in G.P.I. (Ewald and Haddenbrock, 1942; Bini, 1947; Solomon et al., 1948; Yaskin, 1948; Kalinowsky, 1949; Lopez Ibor, 1950), pellagra and pernicious anaemia (Fernandes and Polonio, 1946). It is perhaps not surprising that a search through the literature has failed to bring to light a case of stupor subsequent to a head injury being treated with E.C.T.

From a review of the literature Carstairs (1959) demonstrated that the sharp rise in admissions to mental hospitals since the Second World War has been due to the changing pattern of use of these hospitals, and not to any significant change in the prevalence of major mental disorder. The present paper examines statistics relating to admissions to Scottish mental hospitals in general, and to Dingleton Hospital in particular, in the 15 post-war years 1945–1959, with the object of showing some of the ways in which the character of admissions to mental hospitals has changed over that period.

The passage of small direct currents through nerve cells gives rise to changes in their excitability. For example an outward current flow through the membrane of the soma gives rise to depolarization and a consequent fall in the threshold for excitation of the neurone. When a cell lies in an applied external electrical field a potential gradient exists between the cell body and its distant processes. If this gradient is such that the cell body is negative relative to its processes, the cell becomes more excitable; it becomes less excitable when the cell body is relatively positive.

A previous paper (Lippold and Redfearn, 1964) described the mental changes that can be produced by the passage of small polarizing currents through the brain in human subjects. It became apparent during the course of these experiments that some of the effects persisted for hours or days after the current had been turned off. A persistent excitatory after-effect of surface-positive cortical polarization has recently been demonstrated in the rat (Bindman, Lippold and Redfearn, 1962). It is possible that a similar phenomenon, at the cellular level, is responsible for the long-lasting psychological effects of polarization.

In a series of neurotic twins who are being systematically studied by the Genetics Unit at the Maudsley Hospital, two pairs have been of particular interest.† Both had identified with each other to an extreme degree, yet only one of each pair had a psychiatric illness requiring extensive in-patient treatment. They illustrate the fact that identification can be a feature in monozygotic twins, yet does not necessarily lead to concordance for emotional disturbance.