At the beginning of this century the high rate of “insanity” among immigrants was a matter of considerable concern in the U.S.A. and it has been used as one of the main arguments for curtailing immigration. The problem has been reviewed, and examined with modern statistical methods, by Ødegaard (1932) and Malzberg (1940).

The manifest contents of most phobias concern dangers coming from the environment. It is the degree of those neurotic fears rather than their objects which makes them appear unrealistic. Fears of dangers coming from outside the environment in which the patient lives, such as fear of cosmic happenings, have usually been found to be associated with schizophrenia. Recently the knowledge of our physical environment and the scope of its exploration have been undergoing fundamental changes. This has been reflected in the symptomatology of phobias. The following four patients seen in the psychiatric outpatient department of the United Sheffield Hospitals during the last eighteen months illustrate how a change in the popular concept of physical reality can produce a new type of neurotic fear. The first case is given in greater detail than the others, because the patient's power of verbalization was above average.

The psychometric assessment of memory presents special problems in that inferences regarding this function seem to be markedly dependent upon the conditions under which it is measured. Thus, following exposure to experience X, it is problematic whether a single statement regarding a person's ability to remember X can be made. His ability would likely be a function of the time between exposure and reinstatement (Ebbinghaus, 1913; Luh, 1922; Postman and Rau, 1957) and whether assessment involved recognition, free recall, or relearning (Luh, 1922; Postman and Rau, 1957). Beyond these, the importance of the sensory channel involved in the initial experience or in reinstatement (Thurstone, 1938, p. 86) and the nature of the content to be retained (Benton, 1945) remains relatively unexplored. All of these considerations dictate against accepting differing psychological test measures of memory as equivalent and, conversely, suggest that any generalized statements regarding memory ability should be based upon several different measures.

The illness which was first described by Kraepelin and which he called dementia praecox was more correctly designated as a Zerfallskrankheit (disintegrative illness) by Eugen Bleuler, who called the illness schizophrenia. In this disease, or rather group of diseases, not only does one find characteristic symptoms and symptoms which occur in other functional psychoses, but, if suitable methods of examination are employed, symptoms which are found in gross brain diseases, especially those associated with focal lesions, are also elicited. Apart from this, many other symptoms acquire a new aspect when viewed from the standpoint of neuropathology. This may justify our attempt to consider all schizophrenic symptomatology from the point of view of neuropathology. I attempted to do this in my “Report on Cerebral Pathology and its Importance for Neurology and Psychiatry” which I delivered 21 years ago at the annual meeting of the Association of German Neurologists and Psychiatrists at Frankfort-on-Main. Not much space was devoted to the problem of schizophrenia in this report. However, since that time more neuropathological knowledge has been acquired as a result of the Second World War, and this has added to the not inconsiderable knowledge of neuropathology which we already had in 1936 as a result of the First World War. The increasing number of brain injuries due to road accidents has also increased our knowledge of neuropathology. New approaches to the schizophrenic syndromes have been made possible by this growth of our knowledge of the effects of brain injury. Apart from this, I was able, in collaboration with Professor Leonhard and others, to finish a few years ago the clinical follow-up studies on schizophrenia which I began in 1936. In this work we encountered a large number of schizophrenic symptoms which had neurological characteristics.

This investigation was designed to determine whether significant alterations in the metabolism of nitrogen, calcium, and phosphorus occur in psychiatric patients during the therapeutic administration of electric convulsive treatments. Gour and Chaudhry (1) observed transient changes in serum calcium following grand mal convulsions in a series of patients. Jarvie and Mulligan (2), repeating this experiment in patients receiving muscular relaxants during the administration of E.C.T., failed to demonstrate similar calcium changes. More intimate knowledge of electrolyte metabolism can be obtained by means of balance techniques (3), whereby the degree of retention or loss of a particular substance can be ascertained by maintaining each patient on a constant daily intake and regularly determining the urinary and stool excretion of that substance.

Attempted suicide is a non-fatal act of self-damage carried out with the conscious intention of self-destruction. This is the only definition about which clinicians can be expected to agree. Attempted suicide was, until recently, regarded only as an abortive or unsuccessful suicide. Consequently, it was studied purely retrospectively, which is appropriate for events which mark the ultimate end of an individual. Motives, methods, clinical diagnosis, social factors leading to the suicidal attempts were examined and the available figures were interpreted in the same way as the suicide figures. In the published studies, the number of attempted suicides used to be smaller or did not greatly exceed those of suicides occurring in the same population. It is not surprising that nonmedical research workers should have accepted them as reliable approximations to the true incidence of suicidal attempts, but many psychiatrists have done the same, which illustrates the deceptive magic of figures.

In this paper it is my intention to review some of the central aspects of the psychopathology of schizophrenia. At the outset it would be appropriate to establish the role which psychopathology must play in our efforts to arrive at a fuller understanding of the schizophrenic psychosis. Psychopathology is, as the term itself reveals, a psychological study of abnormal mental functions. It is not primarily concerned with the organic bases for the disturbance of mental activity, but such a study does not imply that the roots of abnormal psychological processes do not in fact lie in somatic pathology. To my mind psychopathology and studies of disturbed brain function in mental disease are complementary to one another. Many distinguished workers in the field of the psychoses have referred to the disappointing results of biochemical and electro-physiological research in schizophrenia. They have suggested that the failure of such research has arisen in part from the absence of correlation between clinical studies on the one hand and physiological studies on the other. Tait (1958) has remarked that although physiological research can provide us with a wealth of data this data will only become meaningful whenever clinicians are in a position to provide biochemists and electrophysiologists with sets of specific questions. The formulation of such questions must depend upon a refinement of our diagnostic categories. Similar criticisms have been levelled against psychological research. In a recent review of contemporary psychological research Rabin and King (1958) have pointed out that the lack of criteria necessary for the selection of a homogeneous group of patients leads to the vitiation of much current psychological research. It is possible that psychopathology may be able in the future to contribute something to the solution of these methodological difficulties which so beset and hamper contemporary research in schizophrenia.

The author has already briefly reported on his investigation of senile paranoid states to the First Meeting of the European Clinical Section of the International Association of Gerontology (Fish, 1959a). He would now like to present his findings in more detail and discuss the relevant psychiatric literature.

The advent of the various tranquillizing drugs during the past few years and their increasing use in mental hospitals have had the effect of drastically decreasing the number of lobotomies performed. At our hospital, e.g., the last lobotomy was performed in November, 1954; previous to that time 131 such operations had been done in seven years. To all intents and purposes lobotomy is a therapeutic procedure no longer used for psychiatric purposes. This may change, of course—it may be decided that for certain patients a lobotomy is still the treatment of choice. Or, it may be that in the years to come lobotomy will be of interest chiefly to medical historians.

Many years ago one of us was introduced by a senior colleague to Thomas Hennell's fine book, The Witnesses (23), and so began in a desultory way to collect accounts of their illnesses written by mentally ill people. We have found that many people know a few books of this genre and speak warmly about their usefulness. One gets the impression that these books are unobtainable. In 1956, after reading Hunter's and MacAlpine's (44) translation of the Schreber Memoirs, and later Schizophrenia, 1677 by the same authors, which consists of Haitzman's account of his illness, we realized that these books had played and could play an important part in the development of psychiatric theory. Indeed, the psychoanalytic theory of schizophrenia derives from the Schreber Memoirs and, although Hunter and MacAlpine rebuke Freud for his extremely selective use of those memoirs, they do not suggest that any systematic study of these writings would be valuable. Psychiatrists of many different persuasions have been given to examining a host of historical, literary, and mythical characters from Moses to Popeye the Sailor; but so far we have been unable to find any systematic study of this uniquely valuable body of information provided by the sick themselves.

The subject of the present communication arose from an incidental observation made during an attempt to establish a Symptom: Sign Inventory for use with all types of mental patients. For some time past all cases diagnosed by psychiatrists as suffering from depression, whether psychotic or neurotic, have been given this inventory. The observation made was that, within the group diagnosed as psychotic, those over 60 years of age did not appear from the inventory to have the same symptoms as those under 60.

This report is based on a survey of 1,716 Chinese patients admitted to the Peking Municipal Psychopathic Hospital during the years 1933–1943. It is mainly concerned with a statistical presentation of the relative frequency of the various mental disorders and with certain other data which may be of interest to psychiatrists and other members of the medical profession.

In an earlier investigation the author (1959) raised the question regarding whether a higher incidence of psychiatric disorders could be observed among refugees who remained in, or came to Norway after World War II. Through a personal investigation of all the (sixty) refugees who were admitted to Norwegian mental hospitals and psychiatric departments during the period 1 January, 1946–31 December, 1955, it has been possible to answer this question in the affirmative and without any shadow of doubt. The author could also show that the incidence of psychoses among refugees in Norway is, for all diagnoses, five times higher than could be expected when compared with a matched Norwegian population. For schizophrenia alone the incidence is less than five times higher, while for reactive psychoses it lies far above this number.

The Sentence Completion Test is now a well-established technique. It is more than sixty years since Ebbinghaus (2) published the first completion test, which he used to assess mental abilities of schoolchildren in Breslau. But it was not until 1928 that the completion method was used for “personality” assessment, when a fifty-item test was used by Payne (11) as part of a guidance programme.

In deep coma the patient usually lies still, without moving. Why doesn't he move? Many will answer, “Because he is unconscious”. This is on the assumption, which seems eminently reasonable, that motor centres are under the control of a higher centre for mind. On voluntary movement, according to this assumption, motor centres receive and obey impulses from the psychic centre. When the psychic centre is paralysed, as in coma, the motor centres lie idle, like men in a factory marking time because the foreman is away and there is no one to tell them what to do.

The widespread use of barbiturates as hypnotics for insomnia has greatly increased the risk of accidental overdosage and the number of suicidal attempts. The size of the problem concerning barbiturates and suicidal attempts is difficult to estimate as only suicidal deaths are recorded by the Registrar General, and his statistics for 1956 (R.G., 1958) reveal that out of a total of 5,282 suicidal deaths, drugs (mainly barbiturates) were second only to domestic coal gas poisoning as the effective agent. Stengel (1958) calculated that six times the number of suicidal deaths gives an approximate estimate of the number of attempted suicides. Locket and Angus (1952) found that of the patients admitted to their Unit, barbiturates were the drug involved in 80 per cent. of the cases and that in 90 per cent. of the cases it had been prescribed for the treatment of insomnia. Locket (1958) also estimated that some 6,000 patients were admitted annually to hospitals in England and Wales for treatment of barbiturate poisoning.

Any particular system which is being conditioned is likely to maintain a certain level of background activity throughout the experimental procedure; either of a discontinuous nature, as, for example, with eyeblink, heart rate and respiratory cycle, or continuously, as in the case of basal skin resistance and muscle tonus. This background activity or level of arousal does not remain constant but usually varies in time, presumably as a result of underlying neural excitation or inhibition. It may increase throughout an experiment if the subject becomes highly motivated, as with the gradients of muscle action potentials observed by Bartoshuk (1955), or decrease, if the subject becomes more relaxed and familiar with the set-up, as Duffy and Lacey (1946) found with level of skin conductance.

In the course of the past few decades various controversial theories have been elaborated on the aetiology of mongolism in an attempt to solve the complexity of this interesting clinical entity.

The voluminous literature reporting the effects of cortical lesions has shown contradictory and diverse findings from the earliest studies to the present (Franz, 1907; Klebanoff, 1945; Klebanoff, Singer and Wilensky, 1954; Meyer, 1957). Some investigators found no losses in intellectual function regardless of the locus of the lesion; others, a temporary loss followed by recovery of original capacity. Still others have reported significant losses following brain damage in the forebrain or other portions of the central nervous system. But for investigators in all three categories, what did “brain damage” consist of? The neurologists Brain and Strauss have observed “The study of psychological problems without an adequate knowledge of the physiology and pathology of the central nervous system can be likened to the exploration of the uncharted seas without the aid of a compass; and yet there are many psychologists who undertake the rash venture” (1955, p. vi). And what of the criteria on which the conclusions were based? An additional source of ambiguity is indicated by the fact that the overwhelming majority of conclusions on “mental” changes by psychiatrists and neurologists have generally been based on clinical or subjective estimates. Measurement, a crucial factor in any study, is of special importance in studies of brain damage and brain function, although despite a multiplicity of tests, there are few measures designed with attention to their unique problems. Tests employed in many psychological studies of brain damage were originally oriented toward quite different problems and had been carefully developed and standardized on non-brain damaged populations.

Since the introduction of reserpine by Kline in 1954 there have been relatively few studies of its use in schizophrenia and most of these have been uncontrolled. It is characteristic of these uncontrolled trials that when the results are assessed, they are described in glowing terms, and the percentage of patients reported as showing “moderate” or “marked” improvement is high.