I should like to express my appreciation and gratitude to the fellows and members of our new College for placing me in the position in which I now stand. The Presidency is the greatest honour our Royal College can confer and the first occupant of the office sets out lacking guidelines or landmarks, without precedents or hallowed practices to constrain or cushion him. He will be expected to lead a democratically elected body of men towards their chosen objectives without falling prey to the dizziness or sense of grandeur that are prone at a height to deceive the senses. I am deeply conscious of the privilege, responsibility and the opportunities for advancing the discipline to which we are dedicated that are afforded by the Presidential office. I can only say that they will always have the first claim on such energies and talents as I am able to command.

In the current state of psychiatric knowledge, clinicians must synthesize their personal view of the nature and cause of schizophrenia from several competing, complementary, and sometimes contradictory perspectives. They are also faced with the necessity of making day-to-day decisions concerning the diagnosis and treatment of schizophrenic illness in their patients. The present study seeks to clarify the relationship between clinicians' opinions on the nature or cause of schizophrenia and the way they diagnose and treat this disorder, as reflected in their opinions on which are the most useful diagnostic signs and modes of treatment.

Reviewers of the literature are unanimous that in schizophrenia the outcome is better in cases where there is a history of stress shortly before the onset of the illness. Zubin et al. (1961) found 89 papers ascribing a favourable prognostic influence to stress and none maintaining that it had a bad or immaterial effect.

During recent years interest in transcultural psychiatry, particularly Anglo-American differences in diagnostic practice and treatment, has increased considerably. In 1965 Willis and Bannister reported the results of a questionnaire study of the opinion of 'senior’ British psychiatrists on the diagnosis and treatment of schizophrenia. Acknowledging the many disadvantages of a postal enquiry of this kind, the present author thought that their study would form the basis for a useful and relatively inexpensive Anglo-American comparison. Consequently, in 1968 an almost identical questionnaire was circulated to six hundred 'senior’ American psychiatrists.

In discussions of schizophrenia, ‘thought disorder’ has a traditional place of prominence. Eugen Bleuler (2) believed ‘disturbances of association’ of ideas to be a fundamental symptom in schizophrenia, and among more recent authors Cameron (3) introduced the concept of ‘over-inclusiveness' to explain not only the thought process disorder, but many other symptoms of this condition.

Dermatoglyphic patterns, especially fingerprints, have long been of interest to researchers in the genetics of schizophrenia, but results of investigations have been inconsistent. Rosner and Steinberg (4) published the first dermatoglyphic study of Negro male schizophrenics, comparing finger and palm prints of 207 patients at Virginia State Hospital with those of 105 healthy Negro males from the National Institute of Neurological Diseases and Blindness Perinatal Study. This is the second report on the dermatoglyphics of Negro male schizophrenics.

In 1963 Coppen and Shaw reported that patients with manic-depressive psychosis showed, on clinical recovery, a significant decrease in exchangeable sodium, and in residual sodium (exchangeable minus extracellular sodium), presumed intracellular, per litre of body water. Coppen, Shaw, Malleson and Costain (1966) found a similar type of shift in mania but the deviation from normal was, on average, more extreme. Although low and high sodium diets had no effects on the distribution of sodium in manic-depressive psychotics, the administration of spironolactone resulted in a significant reduction of residual sodium (Coppen, 1970). The possible involvement of aldosterone in these changes led Jenner et al. (1967) to examine aldosterone excretion in a 48-hour cycle patient and Murphy, Goodwin and Bunney (1969) to examine groups of manic and depressed patients. Murphy et al. found lower rates of excretion of aldosterone in depression than in mania, but Jenner et al. found the opposite.

Recently several communications have been published implicating impaired 3′5′ cyclic adenosine monophosphate (cyclic AMP) metabolism as a causal factor in affective disorders (1, 3, 7, 8, 9, 11). In particular, the urinary excretion of cyclic AMP in manic patients is reported to be increased compared with that of normal subjects, whereas in depressed patients a decreased excretion has been observed (1, 7, 8, 9). These findings form the basis of a theory explaining the systemic and mental symptoms of affective disorders (1).

In 1968, the Veterans Administration and the National Institute of Mental Health organized a multi-hospital collaborative study on the effectiveness of lithium carbonate in acute mania. Two hundred and fifty five newly-admitted patients with this disorder were randomly assigned to lithium or chlorpromazine treatment for a three-week period. Patients were classified as highly active or mildly active on the basis of hyperactivity shown at admission. Results have been reported in a previous paper (7). Briefly, it was found that chlorpromazine was significantly superior to lithium in treating the highly active patient: chlorpromazine acted more quickly than lithium, produced significantly fewer treatment failures, and had a lower incidence of severe side effects. The difference between treatments was less clear-cut with mildly active patients, although lithium appeared to be the better treatment. Both drugs effectively reduced manic symptomatology, but lithium produced fewer severe side effects and left the patient less sluggish and fatigued. The poor results with lithium among highly active patients were attributed to the drug's relatively slow onset of action. As a group, highly active patients on lithium showed relatively little change in manic behaviour during the first week; it was ten days before some patients showed any improvement. Almost 40 per cent of the highly active patients had to be taken off lithium before the end of three weeks because of unmanageable behaviour or toxicity. In contrast, chlorpromazine, with its quick onset of action, generally controlled manic symptoms

Pitts and McClure (Pitts and McClure, 1967; Pitts, 1969) have recently suggested that all symptoms of anxiety and anxiety neurosis itself are caused by a raised blood and body fluids lactate level. As the biochemical mechanism underlying anxiety neurosis they proposed that the excess lactate complexes with, and reduces, the concentration of ionized calcium at the surface of excitable membranes to an extent that causes a disordered nerve activity to manifest itself in the form of anxiety symptoms. In support of this speculation, according to which anxiety neurosis is a biological disease essentially brought on by a lactate-induced hypocalcaemia, Pitts and McClure (1967) quote investigations that have shown that on standard exercise anxiety neurotics tend to produce higher blood lactate levels than do normal controls, and their own lactate infusion study. As pointed out elsewhere (Grosz and Farmer, 1969), neither the former nor the latter, however, can be considered satisfactory evidence.

The development of psychiatry in England in the eighteenth century is particularly interesting because it shows the growth of public concern for the insane which led to the establishment of Public Subscription Hospitals and, later, the County Asylums. The general history of the period has been covered in works by Kathleen Jones, Denis Leigh, and Hunter and Macalpine, and books have also been devoted to the history of individual hospitals founded during those years, such as Bethel Hospital, Norwich (1725), St. Luke's Hospital, London (1751), the Manchester Lunatic Hospital (1766), and the Retreat, York (1792). For affluent patients there were, of course, a number of private madhouses, later officially ‘Licensed Houses', scattered about the country; in 1880 there were 40 of these outside the metropolitan area, and in London and Middlesex 14 are recorded in 1807 and 20 in 1815. The Private Madhouse Act (1774) provided for the provincial houses to be inspected by the local justices. In practice this Act was not very effective (11).

Lack of speech, i.e. dumbness, has long been equated with backwardness, and probably for this reason and because of success in teaching some hearing impaired children to speak, the terms ‘deaf and dumb’ and ‘deaf mute’ have fallen into disrepute. When deafness is profound and prelingual (i.e. congenital or acquired in early infancy), there is a formidable barrier to the development of language. Many deaf children still leave school with poor language, incomprehensible speech and little ability in lip reading and consequently come to rely upon manual communication methods (finger spelling and signing).

The recognition of the need for psychiatric services for disturbed adolescents led to the opening of the first two adolescent in-patients units in Great Britain in 1949. As a result of community pressures and active encouragement by the Department of Health and Social Security since 1964, an increasing number of units have opened. Although the provision of psychiatric services specially designed to cater for the adolescent has gained momentum only in the past three to five years, the demands of this section of the population is underlined by Rosen et al. (1965) who showed, in an American survey of 750,000 clinic patients seen in 1962, that approximately one-quarter were aged between ten and nineteen years—a number representing 6 · 2 per thousand adolescents of the population served. Similar figures, namely, 6 · 6 per thousand (Kidd et al., 1968), were found in Aberdeen, and 5 · 6 per thousand (Henderson et al., 1967) were found in Edinburgh. Since an adolescent psychiatric service was opened in Edinburgh in 1967, there has been a continual increase in the demand for its services, as follows:

This suggests that the previous figures were an underestimate and that psychiatric disturbance amongst adolescents may be much greater than formerly estimated. Furthermore, such referrals do not indicate the demands for help that Approved Schools and children's homes have made. The authors believe that psychiatric skills are most effectively deployed in these settings if the psychiatrist acts as a consultant to the staff, rather than by assessing and treating individual children (Evans, 1963). Even so, demands have far outstripped the available supply of psychiatric time.

Department of Health and Social Security statistics show a steady rise in the use of outpatient services from the inception of the National Health Service; since the Mental Health Act of 1959, the numbers of new outpatient and clinic attendances have increased by one-third and one-fifth respectively (D.H.S.S., 1971). However, as our knowledge of the actual functions of out-patient services and their relationship to in-patient care is at best only rudimentary, the recent article by Mezey and Evans (Journal, June 1971, 118, p. 609) is a much needed contribution towards evaluating these different facilities of the psychiatric services.

In a previous paper (Cheadle et al., 1967) we described a form in use in this hospital since 1961 for rating the work performance of psychiatric patients. The form was shown to possess adequate inter-rater reliability and predictive validity, but it had certain shortcomings which we have tried to remove in a revised version. This (Fig. 1) consists of 16 items of work behaviour each rated on a five point scale and scoreable by awarding o for each tick in the left hand column, 1 for each in the next column and so on, 4 being given for each tick in the right hand column. The lower the score the better the performance.

There is evidence that dependence can develop to tranquillizers and that they can cause states of physical dependence similar to those obtained with barbiturates. Withdrawal manifestations are usually less severe and of shorter duration. They include agitation, restlessness, tremor, muscle twitching, insomnia, anxiety, depression and confusional states with disorientation. After high doses hallucinations, delirium and convulsions can occur.

A high incidence of men with the 47 XYY karyotype has been repeatedly demonstrated amongst inmates of prisons (Bartlett et al., 1968; Griffiths et al., 1967) and institutions of psychologically abnormal offenders (Jacobs et al., 1968; Casey et al., 1968). Although genetic surveys of the newborn suggest that there must be many more males with this karyotype who remain undetected in the general population, the high incidence of this karyotype amongst these highly selected groups remains unexplained. The initial hypothesis that the extra Y chromosome was associated with aggressiveness no longer appears tenable, at least in its extreme form, as studies indicate that men with this karyotype are less aggressive than other men in the same institution (Price and Whatmore, 1967). It has also been suggested (Hunter, 1966) that because of their increased stature they are more likely to be seen as aggressive and dangerous, and that emotional disturbances arise from problems consequent to being tall. Forssman and Hambert (1969) have suggested that some cerebral abnormality might account for the behaviour of these individuals, and point to reports of EEG abnormalities as being in keeping with this. In support of this idea, Daly (1969) has reported finding neurological abnormalities in 10 out of 12 XYY males that he examined. He further suggested that neurological deficits might prove valuable in identifying individuals of this karyotype. Criticism has been made of such conclusions (Kessler and Moos, 1970) on the grounds that all such studies have been carried out on patients in special institutions, and that the prevalence of similar abnormalities in the rest of these populations is not known. The following report describes neurological findings in 23 XYY men and in a group of patients with a 46 XY karyotype from the same institution, matched in respect of age (6 months), intelligence (15 points on WAIS), and length of stay (within two years). All patients were from Rampton and Moss Side Hospitals (two of the English Special Hospitals) and had been karyotyped in a previous survey (see Casey, 1971). Apart from those on anticonvulsant medication, all patients had been off drugs for at least the preceding four weeks. Controls and index cases were seen in a randomized order by one of us (M.J.G.H.) who did not know at the time of examination to which group the patient belonged. The neurological anomalies detected in the two groups are shown in the table below.

The College strongly supports the Abortion Act which, as the growing number of unwanted pregnancies terminated indicates—37,736 in its first calendar year, 54,819 in 1969 and 80,723 in 1970—has worked well since its inception and has been widely applied throughout the country. We are concerned, however, by the fact that is some areas patients are being denied terminations that they would readily obtain elsewhere. In consequence they have either to persist with an unwelcome pregnancy, resort to the private sector in London (or in some other large city) or have recourse to a back-street abortionist. As a result, commercialization of abortion (the ‘abortion racket’) has developed; this has been attended by adverse publicity in the press which threatens to bring a humane, socially enlightened measure into unnecessary disfavour. There are doubtless many reasons why so few terminations are being performed in some parts of the country, but amongst the more obvious would seem to be: regional disparities in numbers of gynaecologists and gynaecological beds; the influence of certain dominant gynaecologists in swaying their colleagues for or against therapeutic abortion; and the different constructions put on the wording of the Act by gynaecologists, the lay public and non-gynaecological physicians.