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.

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.

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).

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.

It is the custom of our times to explain neurological, and, to some extent, psychiatric disorders by reference to a static or diagrammatic conception of the physiology of the nervous system, linked with the findings of morbid anatomy. But, in the words of Riese (1950), expressed in his Principles of Neurology:

“Can the behaviour of a living organism be interpreted as purely mechanical? Though the organism remains submitted to the law of mechanics and physics, and though it is to the benefit of a steady improvement of our factual knowledge to explore the mechanics to the maximum possible, we must recognize that in a living organism mechanics are not left to themselves (which means to chance), but that they are at the service of a directing agency best described as the organism's welfare. The reflex must be conceived as an instrument of this agent. All disorders analysed and described in terms of reflex action are only instrumental ones. Neither the physician's task nor his possibilities extend beyond this limit. The directing forces of the organism will be withheld forever from the physician's acting power, if only for the reason that these forces are just ideas or principles of interpretation, but not perceptible realities.”

Consideration of the aetiology of behaviour disorders in epileptic children has been something of a test case in psychiatry: it divides sharply the “organicists” from the “environmentalists”, while those absorbed in psychopathological theory are given free scope to describe the complexity of dynamic mechanisms without committing themselves as to the ultimate aetiological factors.

Certain conditions associated with mental deficiency derive their name from some characteristic skeletal deformity. One of these is abnormal highheadedness or acrocephaly, a term often used interchangeably with oxycephaly, tower skull or turricephaly. To be sure, certain criteria have been recommended by some workers for confining each of the above terms to different sub-varieties of highheadedness and many alternative names have also been proposed (Günther 1941), but none of these have taken root. A distinction is made by many writers between acrocephaly and hypsocephaly or ordinary highheadedness: it is stated that the essential feature of acrocephaly is not highheadedness in itself but exaggerated upward pointing or angling of the head at some distance along its superior curvature so that, in theory, an acrocephalic head need not necessarily be hypsocephalic. However, it is doubtful if this distinction can always be sustained since many otherwise quite normal individuals have abnormal angling of the skull, while some recorded cases of acrocephaly presented a smooth and rounded profile of their upper cranial curvature in photographs and lateral skull X-rays.

When mongolism was first described, it was considered by some authors to be a form of cretinism (Seguin, 1866), and with the discovery of the effect of thyroid treatment in cretinism, this was tried in mongolism also. The disappointing results diverted attention to other endocrines. Tredgold, in 1929, was recommending a mixture of thyroid, pituitary, thymus, suprarenal and pineal glands, though he did not believe that such treatment was curative.

The value of medical and social services in the domiciliary care of the mentally subnormal child has been under considerable discussion during recent years. The mentally subnormal child is known to show many of the same traits as the normal child when removed from the type of personal relationship between mother and child, which is normal within the ordinary home. It is generally agreed that hospitalization of the normal child under five should be avoided if possible, but it must be remembered that this attitude is equally important in the case of the mentally abnormal or psychotic child. Indeed such children have great difficulty in coming to terms with their environment, and as a result are even more vulnerable to the breakdown of the mother/child relationship than the normal child. It is important, therefore, to look critically at the reasons given for applying for admission to a hospital for mental subnormality, and this study attempts to analyse the reasons put forward in a sample of patients admitted during the years 1955–59, and to discuss possible methods of improving the existing mechanisms.

Only 16 cases of folie à trois have been reported in the English literature (Wolff, 1957). The present case seems worth recording because of the rarity with which this condition is described and the problems it raises.

This case is thought to be of interest because neuropsychiatric complications appeared a relatively short time after the onset of obstructive jaundice.

The first aim of the study reported in this paper was to check Foulds's finding that claims for the success of a treatment were related to the degree of experimental control which authors exercised in their investigations (77). Foulds, from a selection of papers appearing between 1951 and 1956, showed that five studies (6·9 per cent, of the total) were controlled and claimed success, 15 (20·8 per cent, of the total) were controlled and claimed failure, 43 (59·7 per cent, of the total) were uncontrolled and claimed success and 9 (12·5 per cent. of the total) were uncontrolled and reported failure.

Feldman (1951) published a scale for predicting the response of patients to E.C.T. and insulin coma therapy. Using only Minnesota Multiphasic Personality Inventory profiles meeting stated requirements (at least one elevated scale, moderate F scale scores, etc.) he carried out an item analysis of the M.M.P.I. responses of 42 patients who had responded well to shock therapy and 42 patients who had remained unimproved (psychiatrists' ratings). He derived a 52-item scale, scored as an additional M.M.P.I. scale and labelled Ps, high scores indicating poor prognosis. This he cross-validated on a further 100 patients (categorized as recovered, improved or unimproved) and all categories were well discriminated by Ps scale scores.

In a previous paper, Davies and Beech (4) presented data obtained from both clinical observations and psychological tests on normal subjects under the influence of Sernyl. In that paper an account was given of the chemical constitution and action of the drug. It is not necessary to say more here than that this compound is a synthetic cyclohexylamine derivative that was introduced into anaesthetic practice because of its ability to produce analgesia without loss of consciousness. It appears to act mainly at the thalamic level and produces changes in the reception of sensory stimuli. Post-operatively, however, psychiatric disturbances were common and the use of the drug in anaesthetic practice was curtailed. Our interest in Sernyl has centred upon its psychotomimetic effects and its possible mode of action. It has, in fact, been suggested that normal individuals under the influence of Sernyl behave, in some respects, like schizophrenic patients and that this similarity is most striking in the case of thinking processes. In the further investigation of the effects of this drug it was therefore decided to test the hypothesis that Sernyl produces mental disturbances which are characteristic of thought-disordered schizophrenics.

Since Delay, Deniker and Harl (1952) first reported favourably on the use of chlorpromazine in disturbed psychotic patients the extended use of pheno thiazines has contributed to the transformed atmosphere in mental hospital wards. There is still some doubt as to the precise mechanism of action of the phenothiazines. The blocking of arousal responses to afferent stimulation in animals following chlorpromazine has been fully demonstrated (Bradley and Hance, 1955, 1957). The production in man of a “parkinsoniansyndrome” by chlorpromazine and later phenothiazines has been taken as evidence of drug activity as a basal ganglion level (Kruse, 1957). More recent work suggests that chlorpromazine may act by depressing the collateral inflow into the reticular formation from the afferent pathways rather than the brain stem activating system itself (Key and Bradley, 1958).

“A doctor must know not only the virtue of a drug, but also its drawbacks”—

Carling (1960).

Thioridazine is one of the newer phenothiazine derivatives used in psychiatry. Previous workers have reported few serious side-effects with it. The following pilot trial was carried out on male patients suffering from chronic schizophrenia who required nursing in a closed ward.

Most people now accept the value of the tranquillizer or ataractic drugs, which play a major role in individual therapeutic results and in environmental change in major psychiatric hospitals. Numerous surveys have stressed the influence of these drugs and they have recently been confirmed by Brill and Patton (1959) in a twelve-year review of mental hospitals capable of dealing with over ninety-three thousand patients. As the number of patients on tranquillizing drugs (mainly chlorpromazine) increased, so the patients requiring restraint decreased, the discharges increased and the re-admissions decreased: a direct cause and effect relationship was established.

Depression is a serious illness in Western Europe and the United States of America. It is estimated that in 1957 the combined total of suicides in the United States, Britain, France and Western Germany was approximately 30, 000 (1). The attempted suicide rate is considered to be six or seven times as great, which could give a grand total of 200, 000 suicide attempts in that year in these countries. Many of these patients are depressives, as stated in a recent British Medical Journal leading article (2).

Recently many new anti-depressive drugs have flooded the market, the objective being initially to assist and finally to replace E.C.T. as the treatment of choice for depressive states. One such preparation is Tofranil (N-(γ-Dimethyl-aminopropyl)-iminodibenzyl hydrochloride or imipramine). It was first favourably reported on by Azima (1) and Kuhn (2).

The discovery by Kuhn (1957) that an iminodibenzyl derivative (imipramine) was therapeutically successful in depressive illnesses aroused great interest and stimulated clinical trials with the drug in many parts of the world. The results of some of the published reports are given in summarized form in Table I.