I have been deeply moved by your invitation to deliver this year's Maudsley Lecture. Founded to commemorate so distinguished a man, it has become most properly one of the honours of psychiatry.

So little consideration is given in early medical writings to sexual disorders, that it seems that these were, for many centuries, hardly regarded as the concern of the physician. There are a few exceptions. For example: Hippocrates (Airs, Waters, Places XVII-XXII) discussed the part played by constitutional and environmental factors in the causation of impotence among the Scythians. Later, Caelius Aurelianus, according to Zilboorg (1941), while expressing disgust at the debauchery which characterized Imperial Rome, seems to have recognized that sexual perversions were illnesses which, at times, were epidemic in character. Subsequently, and in particular during medieval times, problems of this nature seem to have had a moral rather than a medical connotation. Indeed it was not until towards the close of the nineteenth century that any real insight into the medico-psychological nature of sexual difficulties and deviations became apparent. This new awareness reached its peak following the investigations of Havelock Ellis, Freud, Stekel and others, and the formulation of certain psychoanalytic hypotheses.

Hughlings Jackson has exerted a considerable influence in psychiatry. This statement will surprise most psychiatrists because the work of “the father of British neurology” is not known to have made any direct impact on their specialty. It is true that striking similarities between Jackson's basic principles and those of so-called dynamic psychiatry have for some time been noted. But they have been regarded either as incidental or as indicative of the general influence of the theory of evolution.

Psychiatrists have for long paid attention to mental illness in different communities and cultures. In Java, Kraepelin noted that melancholia and mania were rare and that depressive reactions rarely contained elements of sinfulness (9). Later, Bleuler commented upon differences between English and Irish patients and between Bavarian and Saxon patients (2). Others have described various “culture-bound” syndromes such as amok, the windigo psychosis of the Cree, Salteaux and Ojibwa, latah and Arctic hysteria (23, 5, 8, 11, 26). More recently Tooth has described a special category of “delusional” states in West Africans while Carothers has reported on “ill-defined” states and “primitive” psychoses among the West Africans (22, 4). Other workers have stressed the significance of cultural factors in the distribution of mental illness. Seligman noted in 1929 that confusional states were more common than systematized insanities among the Papuans of New Guinea and could not find any cases of manic depressive illness (17). Berne noted that toxic confusional psychoses rather than the schizophrenias were the predominant illness among hospitalized Malay (1). Carothers related Westernization to an increase in manifest paranoid behaviour among patients in Kenya (4). Similarly Spiro noted that the Ifaluk in the Carolines had violent paranoid outbursts only after Japanese occupation and Slotkin emphasized the paranoid schizophrenia phenomena among acculturated Menomini (20, 19). Opler found that lower class Filipinos had a high proportion of affective disorders and catatonic confusional states among the Hawaiian hospitalized, while Carothers and Tooth in Africa both found statistically low incidences of depression and suicidal states with relatively high rates of confusional states among African natives (13, 4, 22).

Scientific interest in Antarctica has increased greatly since the inception of the International Geophysical Year, but relatively little attention has so far been paid to psychological aspects of adjustment amongst personnel.

Depersonalization has been so frequently reported in connection with incipient schizophrenia that some diagnosticians have regarded it as a pathognomonic sign of schizophrenia. More generally, however, it is regarded as a non-specific psychiatric syndrome since it has been reported in a variety of psychotic, neurotic and neurological disturbances (Ackner, 1954).

It is claimed that there is an association between the occurrence of depersonalization and obsessional personality (Mayer-Gross, Slater and Roth, 1960). The above authors in their textbook quote Shorvon (1946), who found that in his sixty-six cases of depersonalization (forty-six female, twenty male, with an age of onset distribution of twenty under 20 years, thirty between 20 and 30 years, sixteen between 30 and 40 years), no less than 88 per cent. showed obsessional traits in their personalities. Shorvon excluded involutional depression and severe psychotics from his case material. Mayer-Gross commenting on the above paper stated, “While obsessional personalities are preponderant among his cases, he apparently only included a few cases of cyclothymic temperament. In the latter this symptom is frequent, in fact one-third of my own patients were of this type.” He (1935) had in fact drawn attention to the relatively large numbers of extraverted hypomanic characters, who were subject to depersonalization (one-third of his twenty-six cases), but he also found seven out of twenty-six with obsessional personality. (Mayer-Gross found a striking uniformity of age at the beginning of the syndrome, average 26.6 years, distribution two under 20, eighteen between 20 and 30, six between 30 and 40 and a preponderance of women, twenty out of twenty-six.) On the other hand Anderson (1936) found an incidence of 30 per cent. of depersonalization in a series of fifty cases of depression of later life, drawing attention to the often-remarked upon association between depersonalization and depression.

After reviewing the literature pertaining to intellectual deterioration, Yates (1956) concluded that the major determinant of declining vocabulary in hospitalized persons, especially schizophrenic patients, was the length of stay in hospital. The studies on which Yates based his hypothesis were cross-sectional; that is, groups of patients admitted for relatively short periods of time were compared with patients admitted for longer periods. Two studies of schizophrenics showed that long-term patients did not perform as well as short-term patients on vocabulary subscales (Nelson, 1953; Rabin, King and Ehrmann, 1955). Similar decline was noted both in long-term epileptic patients (Capps, 1939) and in non-psychotic residents of old-age homes (Fox and Birren, 1949).

This survey is the concluding part of an investigation of the distribution of abnormalities of the sex chromatin body in the whole of the patient population of Harperbury Hospital. The results of the survey of the male patients of the hospital have already been reported (Shapiro and Ridler, 1960).

Interest has been directed lately to the changes in sodium metabolism in depressive disorders, revealing a complex picture. Gibbons' finding (1960) that recovery with electroconvulsive therapy (E.C.T.) was associated with an apparent drop in total exchangeable sodium, was attributed by Coppen et al. (1962) to failure of his technique to allow for redistribution of sodium between body compartments. Their own work, allowing for different equilibration rates with isotopic sodium, showed no change in total exchangeable sodium during successful treatment with E.C.T., but did not exclude intercompartmental shifts. Coppen had in fact previously shown (1960) that the transfer of sodium from blood to cerebrospinal fluid is abnormally slow in depression, and is corrected during effective electroconvulsive therapy. Demonstration of significant shifts of electrolytes and fluid between, e.g., extracellular and intracellular spaces might thus cast light on important physiological factors in depressive illnesses.

In many electroconvulsive therapy centres atropine is used to mitigate adverse effects resulting from stimulation of the parasympathetic nervous system, while the violence of muscular contractions is controlled with a muscle relaxant. It is customary to secure hypnosis with a short acting barbiturate prior to administration of the relaxant. The first report of the use of thiopentone for E.C.T. was by Rubinstein (1945), and methohexitone (Lilly 25398) was introduced by Friedman (1959). The use of succinylcholine (iodide) for E.C.T. was first reported by Holmberg and Thesleff (1951). The neurological signs during unmodified E.C.T. have been well documented (e.g. Klein and Early, 1948a, 1948b, 1949; Kalinowsky and Hoch, 1952). There is as yet no comparable detailed clinical description of E.C.T. when modified by atropine and a short acting muscle relaxant preceded by a barbiturate. This discussion is limited to some of those signs which may be of assistance in the management of therapy.

Negative conditioning or aversion therapy is most frequently thought of in relation to the treatment of alcoholism. The article by Franks (1958) gives an excellent review of the general principles involved. However, Eysenck (1960) includes several papers in his book to illustrate the effectiveness of such treatment in cases of homosexuality, writer's cramp (Liversedge and Sylvester, 1955) and fetishism (Raymond, 1956). A suggestion made in the latter was that the fetishist may well become such because of an unusual capacity for quickly forming conditioned responses, and therefore by the same token might equally easily respond to a de-conditioning technique. For this reason, the following case was treated by behaviour therapy by a psychiatrist and clinical psychologist in collaboration, and is reported in support of Raymond's (1956) advocacy of this technique of treatment in similar cases.

The majority of subnormal and severely subnormal patients do not present behaviour problems provided planned daily occupation of mind and body is achieved. In a large mental deficiency hospital, however, there is usually a group of grossly disturbed patients whose behaviour is frequently or continually disturbed, and who fail to respond adequately to drug therapy. These patients present a serious nursing problem since they occupy a disproportionate amount of the nurse's time.

A prime obstacle in the training and socialization of the severely subnormal child is behavioural abnormality; drug therapy is most widely used in its control. Until the introduction of tranquillizers, sedatives were normally used. Unfortunately these caused not only motor, but mental retardation. The advent of phenothiazines appeared to offer a solution to this problem.

The purpose of this trial was to evaluate the drug Taractan in the treatment of chronic schizophrenia.

Taractan (chlorprothixene) is chemically α-2-chloro-9-(w-dimethylamino propylidene)-thioxanthene. It is claimed to have neuroleptic and tranquillizing properties as well as thymoleptic activity. It is also claimed to be relatively free from side-effects. This property facilitated its use in a double-blind study.

Although phenothiazine drugs have been employed in the treatment of schizophrenia for approximately ten years, we are still uncertain of the best method of using these agents. Whilst the indications to start phenothiazine medication may readily be agreed, the point at which to terminate such therapy remains debatable. Some psychiatrists stop the drug before the patient is discharged from hospital, some at discharge, some shortly after, but an increasing number recommend the schizophrenic patient never to stop taking his phenothiazine. On the other hand, the national drug bill has reached such proportions that some hospitals are now cutting down the administration of phenothiazines, and continue them only in those patients whose improvement is marked and clearly related to the drug.

Fluphenazine, one of the newest phenothiazine derivatives, has trifluoromethyl and piperazine groups which bring about increase in potency. In Britain it is used in doses of 1 mg. or 2 mg. daily for the relief of anxiety, but American reports indicate that the drug is also of value in psychotic illnesses (Darling, 1959; Niswander and Karacan, 1959; Taylor, 1959, 1960; Darling et al., 1960; Holt and Wright, 1960). Encouraging results were also obtained in a preliminary study conducted in Britain in a group of patients of whom most were psychotic, and daily doses of 2 or 3 mg. appeared to be effective in relieving anxiety and agitation in a considerable proportion of these cases (Gillman and Sutherland, 1961). In reviewing the human and animal pharmacology of fluphenazine, Heseltine (1961) commented on its differences from earlier drugs like chlorpromazine and triflupromazine. The increased potency of the new drug, which in many pharmacodynamic properties may be about 40 times as potent as chlorpromazine, is associated with a rapid and prolonged action, relatively little sedative activity and little or no increase in autonomic and haemodynamic effects. A trial was undertaken to investigate the effectiveness of fluphenazine in the treatment of schizophrenic patients.