An editorial in the British Medical Journal in 1962 drew attention to the fact that research workers have taken relatively little interest in the psychoses of the elderly. The editorial commented on the important paper by Kay and Roth (1961), which analysed the condition known as “late paraphrenia”. Since the publication of this editorial, no significant contribution has been added to the analysis of this illness.

In the development of psychiatry, the paths in our two countries, Great Britain and France, have often run parallel, have frequently come into contact, yet each has retained its individuality and with it a nuance of its own. Pinel, freeing the “aliénés” of Bicêtre from their chains, and William Tuke, establishing the York Retreat, were effecting at almost the same time the same revolution in the treatment of the mentally ill, but the philosophical backgrounds of their actions were different; and though the Royal Medico-Psychological Association and the Société Médico-psychologique are of about the same age, their journals reveal that the preoccupations of their members are not absolutely identical. Certainly the interpenetrations have been fruitful. In establishing in Edinburgh, in 1823, the first formal teaching of psychiatry in this country, Sir Alexander Morison had been influenced by the example of Esquirol, his old master; and Théodule Ribot, the founder of modern French psychopathology, had found his conceptual model and his inspiration in the works of English psychologists, to whom he eventually dedicated a volume which became a classic. But too often, in an age which prides itself on having elevated the study of communications to the rank of a science, the diffusion of information meets obstacles which are more than material or linguistic, and a true medical particularism comes into being. The cultivation of national scientific traditions is a sign of creative originality; but, just as the virtues of hybridization have been demonstrated by the geneticists, the advantages stemming from a knowledge of the efforts and the results of other schools are not negligible for psychiatrists. In this paper I am going to attempt to contribute to this mutual understanding by presenting the recent major trends of French psychiatry.

All animal species have a high potential rate of increase, which must imply a high potential rate of death. Professor Holliday (1) has said: “Something must die, either the sperm, or the egg, or the embyro, or the infant or the adult … Most animals maintain a population at a fairly constant level—there are fluctuations of numbers, but they are fluctuations round a mean. There is a strong element of stability in nature. How is the population fixed at this relatively stable level? Two schools of thought exist. One says that the rules of Malthus apply strictly to the animal world—starvation, disease and predators are the stabilizers and do an immediate and effective job. The other, developed by Professor Wynne-Edwards in Aberdeen, says that animals limit their numbers before starvation does it for them. It is part of the animal's social organization and it is based on instinctive patterns of behaviour. Only a proportion of the population is allowed to breed and those who lose this right in competition become outcasts.”

In 1930, the first report appeared of what was later described as “the first pure case of a man with complete and isolated loss of memory-retention”. At the age of 24, the patient, a skilled tradesman employed in an iron foundry, had been found unconscious at his place of work and was thought to have been overcome by an escape of gas. Some months later he was admitted to Professor M. Reichardt's clinic at Würzburg, where he was diagnosed as a case of severe organic amnesic syndrome consequent upon carbon monoxide intoxication. Over the next few years the patient was exhaustively investigated by Grünthal and Störring, who reported his case in a series of papers (Grünthal and Störring, 1930a, b; Störring, 1931a), later supplemented by a monograph (Störring, 1936). The patient was twice filmed (in 1930 and 1935) and presented at numerous psychiatric meetings and conferences. The sound film was presented by Störring at the International Congress of Neurology in London in July, 1935.

My choice of Kraepelin as a point of departure for this lecture has definite reasons. If one wants to stay within the field of clinical psychiatry (as opposed to psychiatric history), that is as far back as one can reasonably go. By this no slight is intended upon the pre-Kraepelinian psychiatrists. For our topic Henry Maudsley would indeed have been a most appropriate starting point, and by no means for reasons of courtesy. His general point of view is admirably sound as a basis for the scientific study of prognosis in psychiatry. I quote: “There is no accident in madness. Causality, not casualty, governs its appearance in the universe, and it is very far from being a good and sufficient practice simply to mark its phenomena and straightway to pass on as if they belonged not to an order but to a disorder of events that called for no explanation.” On the special problem of prognosis he shows his clinical acumen by stating that the outlook is poor when the course of illness is insidious, but this only means that these cases develop their psychoses on the basis of mental deviations which go very far back in the patient's life, so that in fact they are generally in a chronic stage at the time of their first admission to hospital. Here he actually corrects a mistake which is still quite often made. He shows his dynamic attitude when he says that prognosis is to a large extent modified by external conditions, in particular by the attitude of friends and relatives. Maudsley's dynamic reasoning was limited by the narrow framework of the degeneration hypothesis of those days. He had a sceptical attitude towards classification, which he regarded as artificial and dangerously pseudo-exact. His own classification was deliberately provisional, with very wide groups. He held that a description of various sub-forms of chronic insanity was useless, as it would mean nothing but a tiresome enumeration of unconnected details.

For many years, cases of pernicious anaemia associated with mental symptoms have been described, and interest in these symptoms was renewed following the introduction of liver therapy (Richardson, 1929; Phillips, 1931). Interest later appeared to decline, so that MacDonald Holmes (1956), almost 20 years after the last important clinical review of the subject, could comment with justification that although the cerebral lesions of pernicious anaemia had been recognized for more than a century they were still much less familiar than the lesions which occurred in the spinal cord and peripheral nerves. Since then vitamin B12 deficiency as a cause of mental symptoms has given rise to increasing interest, and this is reflected in recent suggestions that serum vitamin B12 assays should be carried out routinely in psychiatric patients and might be more informative nowadays than the routine Wassermann reaction (Strachan and Henderson, 1965; Hunter and Matthews, 1965).

The signal honour and distinction you have conferred upon me has set me wondering how and why I have merited your selection at this time. It is true that I have worked and spoken for having our own College. I have always profoundly believed in the reality of psychiatry's claim to be the other half and an equal partner of internal medicine, to speak from the position of its own self-respecting identity. It next occurred to me that this sense of identity and personal autonomy is consolidated around the phase of development we call “coming of age”. The hitherto sharp and often painful internal conflicts of adolescence now merge into a greater sense of integration. That means a tolerance of doubt, of ambivalence and of inner contradictions which strengthen where earlier they seemed to threaten stability. So, I reflected, as our rather young discipline has matured to the point of achieving its sense of assured identity—in the space of months or a few years—this Association could accept and wanted to recognize a representative of its own hitherto underprivileged “other half”—the frankly and explicitly “subjectivist” psychotherapeutic or “dynamic” viewpoint.

The assessment of change in psychiatric patients is never easy. The problem is accentuated in the chronic inhabitants of psychiatric hospitals, since the period of treatment and observation may have to be prolonged, and the changes found may be small and gradual. A rating scale can be of value, in recording findings in a uniform manner and in preserving the observations from selective amnesia, so making comparison possible over a long period. In the present communication we report a scale devised by two of us (F.J.J.L. and A.D.H.) for use with chronic patients. This scale summarizes the relevant parts of the examination of mental state found in standard text books of psychiatry, and we have tried to avoid presuppositions about the meaning or distribution of symptoms.

Hypertensive attacks during treatment with amine oxidase inhibitors were first described in tuberculous patients, and were “rediscovered'’ when these drugs were introduced into psychiatry. In an assessment of iproniazid for tuberculosis (Ogilvie, 1955), 4 out of 42 patients experienced “attacks of a most distressing nature”, with severe throbbing occipital headache and high blood pressure. Six years later, similar attacks were observed in 5 out of 212 patients treated for depression with nialamide (Davies, 1959), but it was not until the introduction of tranylcypromine that reports again appeared (Lurie and Salzer, 1961; Clark, 1961). By the beginning of 1963, over 40 such cases had been reported, including several complicated by intracerebral haemorrhage or cardiac failure due to the rise in blood pressure (Songco, 1961; McClure, 1962; Dorrell, 1963).

Reports of significant changes in water and electrolytes during recovery from depression may provide insight into important physiological factors in depressive illnesses. Brown et al. (1963) demonstrated an increase in the extracellular fluid volume in 22 of 28 patients suffering from primary depressive disorders treated with E.C.T. or imipramine. The findings of these authors, which were discussed in relation to previous work on sodium metabolism and water balance in depressive disorders, were thought to support the idea of a shift of fluid from intracellular to extracellular spaces during the response to treatment. Coppen and Shaw (1963) found an increase in total body water, extracellular fluid and a decrease in the residual sodium space on recovery from depression.

Following the classic study of Lindemann (1944) on the various forms and possible outcomes of the reaction to bereavement, little systematic work was done in this field until the last decade. Marris (1958), in a thoughtful but uncontrolled study, interviewed 72 widows whose husbands had died at least 11 months earlier, the mean lapse of time between bereavement and interview being two years and two months. Only 14 of his subjects considered themselves to have recovered completely; 31 reported a lasting deterioration in their health, and 57 reported a continuing difficulty with sleep. More recently, Parkes (1964a), in a study of patients admitted to a psychiatric hospital, has demonstrated that the number of patients whose illness followed the death of a spouse was six times greater than expected, suggesting that bereavement must be one causative factor in the development of the illness. He has also shown (Parkes, 1964b) that widows under the age of 65 consulted their general practitioner because of psychiatric symptoms more than three times as frequently during the six months after the bereavement than they had done during a control period prior to the bereavement. The consultation rate for non-psychiatric symptoms increased by nearly a half in both older and younger widows.

One of the aims of child psychiatry is to support and supplement parents who are having difficulty in their task of socializing their child. At least as important an aim is to keep within bounds the cost of socialization. This cost is certainly excessive when social demands on the parents stifle natural, biologically determined, attitudes to the extent that they provide a noxious rather than a facilitating environment for their child.

The literature on female alcoholism is relatively scanty. The few reports that have been published suggest that the female alcoholic is different from the male alcoholic: for example, Lysansky (1957) stated that American female alcoholics start to drink later, lose control later, drink alone, prefer wine and have fewer arrests or admissions. Perhaps her illness is also more severe: Fort and Porterfield (1961) discovered in their sample that the women required a much shorter length of time to become alcoholic than did the men; the phases of the process were less distinct and nearly all the women had serious personality difficulties or had experienced strong emotional stress. Another American author, Rosenbaum (1958), thought that female alcoholism was an expression of personality misdevelopment, and produced some evidence to support this view. However, he also demonstrated that in married female alcoholics the husband's own heavy drinking, as well as his non-constructive attitude towards his wife's drinking, contributed to the wife's illness.

The psychoses of infancy have long been a matter for controversy. The nature of the disorders, their aetiology, relationship to adult forms of psychosis, long-term outcome and response to treatment are still areas of disagreement among clinicians. Follow-up studies should provide information relevant to some of these problems. Unfortunately, the findings of published investigations have been contradictory. To a large extent contradictions appear to be related to differences in diagnostic criteria, but the failure of many writers to describe their cases adequately has made it difficult to assess the significance of possible differences.

The study of the natural history of a mental illness is important because it may contribute to the diagnosis, management and prognosis of the illness and provide a means of evaluating the effect of therapy. Chapman (1963) has enumerated the difficulties which are responsible for the scanty extensive follow-up studies in neurotic patients. In recent years various new drugs have been introduced to the field of psychiatry and many are claimed to be effective in the treatment of neurosis, but their treatment results cannot be convincingly gauged until the course and prognosis of neurosis are better known. As far as obsessional neurosis is concerned there have been a few major follow-up studies carried out in European countries by Lewis (1936), Müller (1953), Rüdin (1953), Pollitt (1957), Ingram (1961a) and Kringlen (1965), but it would not be legitimate to transfer their findings without qualification or caution to Asian countries in view of racial and cultural differences.

Most of the water and electrolyte studies in mental illness have been carried out on patients suffering from periodic disorders and have been reviewed by Crammer (1962). Coppen and Shaw (1963) found increases in total body water and extracellular fluid and a decrease in residual sodium space on recovery from depression. Manic patients with a high vocal productivity were found by Anderson et al. (1964) to have a negative sodium balance, low plasma potassium levels and a positive potassium balance. Depressed patients with a low vocal productivity had a reduced rate of sodium loss and higher plasma potassium levels. Dawson et al. (1956) found extracellular expansion on spontaneous recovery from manic or depressive attacks. The purpose of the present study was to investigate variations in total body water and its distribution in manic-depressive psychosis. The investigation was complementary to a similar study of variations in body composition during recovery from depression reported by Hullin et al. (1967).

Many psychiatric symptoms have been described in pernicious anaemia, including depression, manic excitement, paranoid states, confusional episodes, and dementia. Although vitamin B12 deficiency is known to produce neurological symptoms there is much less certainty about its role in producing mental symptoms. Despite this uncertainty, it has been asserted that carrying out vitamin B12 assays on psychiatric patients will enable doctors to cure for good severe disabling disease which otherwise may end in chronicity (Edwin et al., 1966). Routine examinations to exclude pernicious anaemia have been advocated for all psychiatric patients (Strachan and Henderson, 1965; Hunter and Matthews, 1965). A prudent preliminary is a critical evaluation of the causal relationship between vitamin B12 deficiency and individual psychiatric syndromes.

New methods of treatment often prove to be valuable tools of clinical investigation. The advent of antidepressant drugs enhanced knowledge about depressive disorders, while the introduction of psychoanalytic techniques yielded a rich harvest from the field of psychopathology. Yet another technique which can throw fresh light on psychopathology is electric aversion, a method now used increasingly in the treatment of certain sexual disorders. With this method separate symptoms can be treated in turn, and their interrelations can thus be changed and studied. With careful clinical control and measurement we can examine the importance of various aspects of sexual disorders hitherto open to observation but not to detailed modification.

It is generally accepted that the obsessional personality (obsessoid, anal-erotic character) is the premorbid personality most frequently associated with obsessional neurosis. Freud (1908) described the triad of traits of orderliness, parsimoniousness and obstinacy which characterizes this personality. He considered that these traits were due to reaction formation against and sublimation of anal-erotic activities and aggressive impulses into socially acceptable forms of behaviour. According to this view the anal-erotic character and obsessional neurosis share a common developmental basis—the neurosis represents a failure of repression, the regression to the anal-sadistic level of libidinal organization and the use of defences against excessive hostility.

This study, in two parts, compares the immediate and more long-term outcome of two groups of schizophrenic patients admitted to hospital before and after the introduction of pharmacotherapy in the form of reserpine and the phenothiazines. There have been differences of opinion as to whether the undoubted improvement which has occurred in the prognosis of schizophrenia, at least in the short term, since the introduction of chemotherapy has been due to the use of these drugs, to changes of administrative treatment, or to both. There has been evidence from mental hospital statistics (Shepherd et al., 1961) that changes in outcome began before the introduction of the drugs and were almost certainly related to the changes of administrative treatment or institutional management which have occurred in the mental hospitals over the same period. It may well be that the use of drugs has facilitated these changes as well as having a more direct effect oh prognosis, but the relative importance of these two factors is difficult to assess from mental hospital statistics. Comparison between results obtained in different hospitals is also of limited value because of the number of uncontrolled variables. There would seem, therefore, to be an advantage in the more detailed examination and comparison of a smaller number of patients admitted to the same hospital, and the present investigation is of this type. The material consists of two groups, of 50 patients each, admitted to the Professorial Unit at the Maudsley Hospital in the years 1952/53 and 1956/57 respectively. Since the policy throughout has been to admit only non-compulsory patients for relatively short-term treatment, administrative changes in this hospital between the two periods are likely to have been minimal. The aim was to compare both immediate and long-term outcome in the two groups and to examine the effect of a number of variables on this. The short-term outcome will be considered in the first and the long-term outcome in the second paper.