I appreciate very deeply the honour of being invited to deliver this the seventeenth Maudsley Memorial Lecture. I also feel the responsibility of adequately fulfilling a task so well carried out by my predecessors and so brilliantly initiated by Sir James Crichton-Browne. I never had the privilege of knowing Henry Maudsley, but Sir James's description of his fellow York-shireman as having “a dash of Wuthering Heights about him” illuminated him for me as by a flash of lightning. It has been said that his last book, Organic to Human, embodies his philosophy, which may be summed up in the principle of unity of the human organism and its continuity with the rest of Nature's processes. His Pathology of Mind also bears abundant testimony to his deep and life-long interest in the subject on which with some temerity I am venturing to address you. Whether I should have been rash enough to do so in his presence is another matter. I recall the fate of “a certain clergyman” whom Dr. Samuel Johnson blasted into silence by a single thunderbolt, and I fear that Dr. Henry Maudsley's keen and logical mind would pounce on some loose joints in my argument. So I crave your indulgence.

The subject of the following record was a married man, aged 40, whose business had brought in an income of about £2,000 per annum. The onset of his illness dated from an accident which was said to have occurred about seven months before he was seen by us. According to the history obtained from the wife it appeared that as he was passing a building in course of erection a fairly large piece of iron fell from the scaffolding and struck him on the left side of the head. He did not fall, but picked up the piece of iron, walked into the building and interviewed the foreman. He then went home, his only complaint being of headache. The wife said she noticed a swelling on the scalp, but as there was no bleeding or wound she did not send for a doctor immediately. The patient was put to bed and is said to have been sick on two occasions. As he did not improve, he was taken, after six days, to the out-patients’ department of a general hospital, where the doctor who saw him attributed the condition to concussion. He was admitted four days later and remained for three weeks. The report from the hospital stated that the patient complained of headaches, became easily irritable and lost all power of control. He is said to have been sleepless, but no sickness had occurred. There was no mention of any external damage to the head, and X-ray examination of the skull revealed no injury. The blood Wassermann reaction was negative and the blood precipitation test was normal. No physical signs of disease were discovered. The wife stated that while in this hospital the patient chased one of the doctors down the stairs. Soon afterwards he ran away from the hospital, telephoned to his wife and was taken back by her, remaining a further week. He then returned home, and after a few days’ rest resumed work. He was unable to continue as he became excitable and irritable, and on one occasion “smashed his office up”. He was seen by his own doctor, who expressed the opinion that the accident had undoubtedly caused a hæmorrhage inside the skull, and that the clot so formed was responsible for the patient's mental disability. Ten days later he was examined by a distinguished neurologist, who also expressed the opinion that a blood tumour from bleeding within the membranes of the brain was the cause of the symptoms. The patient gradually lost interest in his work, stayed at home and spent most of the day in bed, preferring to be left alone. He became violent and on more than one occasion attacked his wife.

Barbital therapy has aroused more interest than any other method of narcotic treatment. The reason is that barbital narcosis offers a new means of establishing contact with hitherto suspicious, seclusive and inaccessible patients. It is the quickest and most effective method of inducing sleep and rest in various maniacal states. Furthermore it is a potent agent in terminating the course of many acute psychoses. Barbital therapy, being empirical, and to some extent experimental, is difficult to define. It denotes more than the mere induction of continuous deep sleep. In fact, it denotes an organized scheme whereby physical and psychic rest, increased suggestibility and alteration of affect are used together to restore normality.

The subject of the fate of sodium barbitone in the body appears still to be a valid subject for discussion; various workers have investigated the excretion of the drug in the urine of normal persons and persons suffering from bodily—not mental—illness.

It has long been recognized that disturbances of the thyroid, such as cretinism, myxœdema and some cases of Graves's disease, can give rise to mental symptoms. Of recent years, however, other endocrinopathies have been investigated from the psychological standpoint, and in nearly all cases evidence of some abnormality has been found. For example, Werner (1) examined 53 castrates, 48 cases of involutional melancholia, and 96 women of menopausal age, and found marked similarity between the mental symptoms occurring at the menopause and those in involutional melancholia, and presumed that they were both due to the same cause—ovarian dysfunction.

Irritability is used in this paper in its popular sense as “the quality or state of being easily annoyed or excited to anger”, according to the definition of the Oxford English Dictionary. I leave it an open question how far other meanings of the word—especially “the condition of being excessively or morbidly excitable by or sensitive to the application of an external stimulus”—have anything to do with the definition of irritability as an affective state. A detailed description of the specific emotional quality of irritability would be of little help to someone who had never experienced it. Irritability might be characterized by its accelerated time factor (in contrast, e.g., to sadness, with its slow time factor), by its tension and proneness to release in outward expressions, and by its unrest. But all such characteristics are only descriptions of the same happening looked at from different angles.

Provision for the observation of cases of mental disturbance occurring in the administrative and the user area of the Liverpool Corporation is made in one of the city institutions, Smithdown Road Hospital. In this large general hospital are located two special divisions, containing 180 beds, one for female and one for male patients, and to the wards of these divisions are receivable all cases of attempted suicide occurring in Liverpool.