Nyasaland is a narrow strip of land 40,000 square miles in extent. It lies approximately between latitude S. 9’ 45” and 17’ 15”, and longitude E. 33’ and 36’. It is bounded on the North by Tanganyika Territory, on the East by Lake Nyasa and Portuguese East Africa, and on the West by Northern Rhodesia and Portuguese East Africa.

The sensory material which provides the essential data for conscious activity is conveyed to the higher functional levels of the brain by impulses which stream up the olfactory tracts, the optic tracts, and the tracts of the brain-stem and spinal cord. With the exception only of the olfactory impulses, all these sensory impulses are filtered through the thalamic region of the brain, or diencephalon, before they can be relayed to the cerebral cortex which forms the anatomical substratum of the more elaborate mental processes. It is an interesting fact that, while the functional localization in the cerebral cortex and the functional localization in regard to the numerous fibre tracts in the brain-stem and spinal cord have been established in quite considerable detail by anatomical, physiological and clinical studies extending over many years, the localization and the connections of the various relay mechanisms in the diencephalon still remain obscure. Since the nature of the sensory material which is delivered to the cerebral cortex depends ultimately on the influences and modifications which may be imposed on the afferent impulses during their passage through the diencephalon, it becomes a matter of extreme importance, from the point of view of the study of the physiology of sensation and of psychological interpretation of sensory experience, that attention should be concentrated on this diencephalic mechanism. The minute anatomy of the diencephalon has recently been worked out in great detail, and it is now the task of the anatomist, physiologist and clinician to discover the functional significance of the numerous cell groups and fibre tracts which have been defined.

When one compares the present state of psychiatric research with that of neurological research, one finds, in the former, an astonishing confusion of contradictory viewpoints. This confusion would, I believe, be resolved if research workers in psychiatry embodied in their creed certain of the principles which Hughlings Jackson unceasingly laboured to establish.

Progress in general medicine is brought about by clinical observation or carefully controlled experimental research. In psychiatry there is little opportunity for the latter approach. One of the few methods available at the present time is the use of intoxicating drugs. It was Kraepelin who first emphasized the importance of studying psychological changes produced by drugs. Following his lead many observers have tested their action on various psychic faculties. Copious data have been collected about such agents as alcohol, caffeine, hyoscine and cocaine. But the value of these observations in bringing about an understanding of the psycho-pathology of the major psychoses is limited, since it is rarely possible to produce the picture of a true psychosis without giving the drug in amounts sufficient to bring about dangerous or chronic intoxication.

Since the time of Ferrier and Hitzig, the effort to localize functions in the cortex has been elaborated until at one time there was thought to be a veritable mosaic of centres in the brain. This line of development has repeatedly been interrupted by investigators who denied the possibility of localization. In this paper we shall refer more particularly to the work of Goldstein, who in numerous papers, and in his new book, Der Aufbau des Organismus, has launched an attack on localization, which by virtue of its systematic approach outdoes all previous attempts of the kind. The chief objects of his scrutiny are the theoretical and philosophical principles of cerebral localization. Two of the ideas stressed by him may be anticipated here; the need for defining what is meant by “symptoms” in cerebral pathology, and the importance of observing the general behaviour of patients with cerebral lesions. These ideas are well in conformity with the general methods of psychiatry.

In the consideration of sinus sepsis in mental disorder it is first necessary to define in our own minds what we understand by the terms used, and their joint significance. A short summary of work already done is therefore given.

My first duty is to thank you for the honour you have conferred on me in electing me President, and to welcome you all on your visit to East Kent and Folkestone for, I think, the first time in the history of the Association.

Present-day medicine tends, where the ætiology of a disease is obscure, to rely too much on the wholesale suspicion of several viscera. It is, therefore, necessary to consider those factors which lead us to the supposition that the liver is at fault in epilepsy.

The material to be presented in this paper is based on the association-motor records of 100 normal controls and 297 psychiatric cases examined by this method during the past three and a half years. The procedure introduced by Luria (1) in 1932, and subsequently modified and adapted by us to meet the expediencies of everyday clinical practice, consists of Jung's word-association technique combined with motor activity.

Adolf Meyer writes, “In the end our task is the amplification and specification of the complaint, expressed in the most factual objective and potent terms”. Robert Hutchison also emphasizes the importance of the complaint when he stresses the presenting symptom in his treatment of medicine. A patient always comes to his physician with some complaint, which it is the duty of the physician to investigate and treat. In the majority of cases the complaint is a bodily one; the patient goes to his physician complaining of an ache or pain or some other bodily discomfort. This bodily complaint may or may not be due to some physical illness. In Sir Walter Langdon Brown's words, “Some are unhappy through illness, some are ill through unhappiness”. This paper deals with those patients who have bodily complaints for which no adequate physical basis can be found. This condition is now known as hypochondriasis.

I hope it will not be a waste of time to begin by seeing what can be meant by prognosis in this difficult kind of illness. Prognosis is often conceived as the natural history of disease—or the course it will follow if it is not interfered with. Treatment is valued for the good modification it produces in this “natural” course of events; it may hurry up the processes of recovery or it may bring about recovery that would not otherwise occur, or it may lessen the harm the disease does; in other words, the efficacy of treatment is assessed by the changes produced in the time the illness takes and the shape it takes. In the case of such a disease as malaria, this conception of prognosis, and this use of it for assessing treatment, can be demonstrated. In psychiatry, however, one is not as a rule dealing with parasites, bacteria, or other exogenous agents which live and exert their influence in a definite order of time and place. Causes of mental illness have no set sequence or constancy. Those external to the patient are as variable and manifold as the pattern of daily life around us, and those intrinsic in him are seldom capable of forcing their way and becoming manifest as illness, no matter what befalls the patient. They are for the most part dependent on circumstance, and of their particular transmission and manifestation we know little; we infer hereditary and constitutional causes with good grounds, but of the details of heredity in any of the individual forms of mental illness we cannot be sure. Consequently we cannot find now any accuracy of prognosis, in the sense of predictable sequence in an individual, based on comparable experience of many others; the variations will be too many; we may expect such accuracy when we know more of the nature and mode of transmission, and of the influence of external circumstances upon time and form and degree of manifestation of each kind of mental illness. Without accurate knowledge of how the causal and modifying factors act, prognosis must be uncertain to a greater extent than in many other illnesses. In medicine, it is true, prognosis can hardly ever be exact, but here it is more inexact than usual.

In dealing with the question of visual impairment in cases of so-called constructional apraxia in a previous paper, I had occasion to discuss arguments put forward by Erich Feuchtwanger, who had proposed to abandon the term “apraxia” for this condition and to call the disturbance “agnosia”. My conclusion was in favour of the original concept of Kleist, who had put the ailment among the apractic syndromes. This, however, makes a detailed analysis of the motor activities and their disturbance in constructional apraxia necessary in order to define its place among the known kinds of apraxia.

Renal dysfunction is so commonly present in cases of mental breakdown that it is of interest to know whether it is especially associated with any definite clinical type or types of mental disorder. In an endeavour to ascertain this, cases have been selected from recent admissions in which the form of disorder from a clinical point of view appeared to be sufficiently marked to warrant placing them in a definite category. Many cases present such a mixture of cycloid, schizoid, confusional or paranoid indications that in an investigation of this nature the selection of sufficiently clear-cut types from a clinical standpoint is not altogether an easy matter. To determine the degree of concentration and polyuria, Rosenberg's modification of the Volhard test has been adopted. It involves little discomfort to the patient and is as follows:—

Psychiatrists will welcome Piney's recent preliminary communication (1) on the possible significance of certain physical characters. A series of measurements of about 500 bodies revealed that a very high number of suicides among the general population occurred in persons showing a body-length-leg ratio of over 50, i. e., the leg-length being more than 50% of the total body-length. Piney believes that persons of this type, among other abnormalities, have such mental characters as may lead to suicide. He raises the question whether body-length-leg ratios of over 50 are commoner among the inmates of mental hospitals than in the general population.

In view of the increasing use of intravenous sodium evipan as an anaesthetic, any contribution to the knowledge of its pharmacology would seem to be of value. It is known from experimental work and from clinical reports that injection of this drug causes a depression of both respiration and blood-pressure, and that jactitations or twitchings are often present during induction. The report of the Anaesthetics Committee of the Medical Research Council (1) states that there is generally a decrease in the rate of respiration, and that there is a transient fall in systolic blood-pressure of 20–30 mm. Hg. Weese (2) observed a decrease in rate and amplitude of respiration, and a fall of blood-pressure of not more than 20 mm. Hg. Jarman (3) found a fall of 20 mm. or more.

The following paper represents an attempt to determine more precise prognostic criteria in the large group of the depressions of later life, to find if possible some other guiding lines than the relatively rule-of-thumb principles which obtain, freed as far as possible from debatable preconceptions as to the existence of an “involutional melancholia” or other specific diagnostic label. Obviously in such a group the influence of the menopause and involution periods might be expected to be prominent.

A one-sided approach to any question, which is always suspect, becomes a very real danger when it concerns medicine. It is the purpose of this paper to draw attention to certain half-truths which have arisen in this way in connection with fear. Fear, like pain, is a danger-signal, called into existence to draw to the individual's notice the presence of some threat to his welfare. It has, therefore, ultimately a protective purpose with a direct relation to self-preservation.