Round about thirty-five years ago, when I was first introduced to the affairs of our Association by two of my chiefs, A. W. Daniel, who was secretary of our Education Committee, and John R. Lord, who officially or unofficially filled almost every other available office—at this time I became aware that there were two categories of President; those elected because of their professional eminence, and those who were rewarded for their services to the Association—and of course there were many who qualified under both headings. Now, in spite of Dr. MacNiven's generous words, I feel that my own election has come about entirely through the kindness and indulgence of our members. It is recorded in divers places in our annals that a warm welcome is traditionally extended to newly-joined members, and I can testify that I have throughout experienced this kindness at your hands irrespective of the rank I happened to occupy or of my success or lack of success in the promotion race. For this experience, of which today marks the culmination, I am truly grateful; and I can confidently claim that in loyalty and affection towards the Association, though in no other respect, I can stand comparison with the greatest of my predecessors.

The Presidency of this Association carries with it an opportunity for service commensurate with the challenge of the time, and I am grateful that you should think me worthy of this high honour and fit for such responsibility at a crucial phase in the development of psychiatry. Events will show whether you have been wise in your choice, but however that may be you can be sure of my utmost effort on behalf of the Association.

The 120th year of our Association's existence is nearing its end and we are approaching the actual 120th anniversary of its foundation. Through the kindness of the Management Committee we are able to meet at its birthplace, Gloucester, and to visit the hospital where it was conceived and brought into existence. At that time known as the Gloucestershire General Lunatic Asylum, and now as Horton Road Hospital, it is one of the oldest buildings continuously in use for the care of the mentally ill.

Permit me to begin by saying how pleased and proud I am to have received the invitation to deliver this year's Maudsley lecture. This is, I think, one of the highest honours that our psychiatric confraternity can confer on any of its members, and is something that the recipient will treasure as an enduring reward.

I am going to give sketches of the lives of three notable nineteenth-century psychiatrists who were associated with and lived in my own county of Warwickshire.

The diagram, which has no relation to brain structure, represents the way in which, in terms of function, mood is regulated by a mechanism which is disordered in cases of pathological elation and depression. It illustrates the points in the regulation mechanism at which physical treatment with different agents can be applied. This theoretical model reconciles the following observations:

The following are summaries of work carried out at Powick Hospital, Worcester, as a project approved by the Medical Research Committee of the Birmingham Regional Hospital Board, which also gave financial assistance.

This thesis gives an account of the use of cortisone and adrenocorticotrophic hormone (ACTH) in the treatment of prolonged comas occurring in the course of deep insulin coma treatment. Cases in which neither hormone was used are also included. The pathology and aetiology of this type of prolonged coma are discussed and a classification of the cases seen is made.

The descriptive study reported here has three main objects: to describe in detail the natural history of a group of obsessional patients; to compare the findings in this group with those in comparable groups of hysterics and anxiety neurotics; and to find in what ways a sample composed of in-patients of a mental hospital differs from other groups of obsessional patients previously described.

The present paper is based on the study of the drinking habits of British seamen interviewed during a recent journey.

Kraepelin's diagnostic classification of the endogenous psychoses received world-wide acceptance, but today it is generally considered to have failed and is at times rejected by some workers with a few scornful words. This is not due to Kraepelin's own work but is the result of the way in which his successors have used his concepts. Kraepelin himself was not satisfied with the rough division of the endogenous psychoses into the two forms of manic-depressive insanity and schizophrenia, or as he termed it, dementia praecox. He, in fact, never ceased trying to isolate more disease entities. Thus, for example, he differentiated a large number of special forms of schizophrenia. Although he defined the two major groups of endogenous psychoses, this did not mean that he limited the number of diagnostic categories. On the contrary, he investigated all special forms of mental illness very carefully. If he saw a clinical picture which was unknown to him he would say, “So far I do not know this clinical picture, we should describe it adequately, perhaps other cases will occur as well, which will allow the isolation of a characteristic clinical picture.”

Have there been changes in the clinical picture of schizophrenic illness over the past hundred years? Or, to put the question more precisely, are the schizophrenic patients of the 1950s any different phenomenologically from their counterparts in the 1850s?

Recent studies (4, 5, 9, 14, 20) have aimed at determining the presence or absence of an increased incidence of psychosis in the nineteenth and twentieth centuries. Opinion is evenly divided as to whether the social changes of the twentieth century have significantly altered the epidemiology of psychotic illness. In spite of an increasing preoccupation with social psychiatry (13), the psychiatric literature is silent on the vital question “Have the changes of the past hundred years altered the clinical picture of schizophrenic illness itself?”

The present study, comparing a selected group of schizophrenics of both sexes from the 1850s and 1950s, begins the search for information on the change or lack of change in this important condition over the past hundred years.

The paraphrenias raise a number of problems common to many other disorders in the field of psychiatry, and their solution might therefore advance knowledge in a number of directions. The relationship between paraphrenic, paranoid and schizophrenic illness has long been disputed, and no view at present commands general acceptance. It has seemed to us that these controversies have often turned upon unacknowledged assumptions as to whether clinical, prognostic or genetic criteria, or all of these, were to be employed to decide the issue.

In the psychiatric literature in English there is a tendency today to deprecate speculative neurophysiological theories of the “functional” psychiatric disorders, while little is done to halt the flood of far-fetched and untestable hypotheses of the “dynamic” psychopathologists. The present author believes that it is legitimate to postulate a neurophysiological basis for schizophrenia in the hope that those with a more adequate knowledge of neurophysiology will be obliged to re-examine the problem of schizophrenia more fruitfully. Conrad (1958, and Fish, 1960) has given a very interesting interpretation of acute schizophrenic symptoms, so that his approach to schizophrenia forms a very convenient starting point for further speculation. This worker's views will therefore now be presented in some detail before the present author's theories are discussed.

Headache is a common problem (Rangell, 1953). Cohen (1939) concluded that relatively few cases were organically based and Shapiro (1955) in an American series found that only four out of a hundred cases presenting with headache could be explained on an organic basis, even though there are fifty odd causes of the symptom (Harris, 1936).

The history of medicine reveals man's search for drugs to ease his diseases and possibly cure them. Advances have been made pharmacologically in the treatment and prevention of many infectious diseases. While psychiatry has benefited from these discoveries in the treatment of certain infections of the central nervous system, in general, the treatment of psychiatric diseases remains largely empirical. The psychopharmacologic treatment of psychiatric diseases continues to be based on the presenting symptom-complex of the patient; this is because the aetiology is still unknown, for in reality our explanations do not explain. The phrenotropic drugs currently used in psychiatry are important for their pharmacodynamic effect since they change the cellular environment in which mental processes are maintained. Pharmacodynamic research in psychiatry has revealed possible neuroanatomical sites and many biochemical effects of these drugs. The specific correlation of these findings with clinical effects is lacking. When this is accomplished, it is probable that better drugs will be developed.

The discovery that iproniazid benefits certain subjects with depression, linked with the demonstration that it inhibits the enzyme monoamine oxidase (MAO), led to the hypothesis that inhibition of MAO was the essential mechanism by which iproniazid caused relief of symptoms (Pletscher, 1959). Iproniazid, unfortunately, can produce serious toxic effects, particularly on the liver (Pare and Sandler, 1959), and this has limited its clinical application. For this reason a search has been made for MAO inhibitors with an effective anti-depressant action yet without the serious toxic effects of iproniazid. Among the newer compounds for which such claims have been made is N-isonicotinoyl (-N-N-benzylcarboxamidoethyl) hydrazine or Nialamide.

The efficacy of anti-depressant drugs, including imipramine and the so-called monoaminase inhibitors, and their potential as a replacement for E.C.T. remain undefined. Imipramine, which has been most extensively studied, has been shown to produce an initially lower improvement rate than E.C.T. in depressives, though after six months the results are little different (Kiloh and Ball, 1961). Dewhurst and Pare (1961) have reported that the quality of improvement in the cases who improved with nialamide in their partially blind trial was comparable to that seen with electroplexy. There is still a lack of controlled trials on the monoaminase inhibitors, particularly as regards patients sufficiently disturbed to warrant hospitalization. Harris and Robin (1960) found no evidence that phenelzine influenced recovery in these patients.

The early investigators in the field of perceptual isolation were at McGill University, especially Bexton et al. (1954). Since then there have been many subsequent works and papers on the subject. In general, published results of this type of experiment can be divided into two groups. Sometimes marked sequelae to sensory deprivation have been described (Bexton et al., 1954 and Goldberger et al., 1958). Such disturbances included thinking, imagery and time appreciation, together with delusional and hallucinatory phenomena. On the other hand, at Princeton University, Vernon et al. (1956), under very carefully controlled experimental conditions, found virtually no sequelae. A paper published from this hospital (Smith and Lewty, 1959) described a silent room which was designed, constructed and standardized to a mean sound pressure level difference of 80 decibels. (Measurements made at octave intervals from 80-10,000 c./sec.) In this particular room 20 volunteers spent varying periods from 5 hours 50 minutes to 92 hours 20 minutes under conditions of partial and complete sensory deprivation. We used a room so as to mitigate the physical effects of reduced somatic activity and fur gloves were used instead of the more common cardboard cylinders, which after a period of time produce a great deal of skin irritation and indeed abrasions, and introduce a great deal of unnecessary complications into a study of pure sensory deprivation.

Studies which have investigated differences in pain tolerance between extraverts and introverts have reported that the former can tolerate pain better than the latter (Petrie, 1958; Poser, 1960). Nevertheless, behaviourly it was noticed that extraverts appear to complain of pain or discomfort readily and generally to “give voice” to their feelings more than introverts, who incline to “grin and bear it” and make light of past painful experiences. Furthermore, it has been shown in drug studies that subjects react differently to pain inflicted in a laboratory to that caused in other (i.e. natural) ways even if this be more severe (Beecher, 1957). It was therefore decided to investigate this discrepancy by testing subjects undergoing “natural”, i.e. not experimentally inflicted, pain, and women in childbirth seemed a suitable group to approach.