Despite available therapies, mental disorders are the predominant chronic diseases of young people. Increasing the validity of descriptive psychiatry is now essential. Mathematical approaches can help characterise clinical phenotypes and aid both causal research and therapeutics in the community and the clinic.

I propose in this lecture to pass in review the various forms of insanity which you find in the Table, and by a brief reference to their history and symptoms to show you how they really are distinct forms of disease, and that in each or nearly so there will be found some peculiarities in the symptoms or progress of the case which render it somewhat different from other forms of insanity; such in fact as in many instances would lead you to detect the cause, and such certainly as to justify us in classifying it as a distinct form of insanity.

The nature and extent of the sexual abuse of children and young people and the pervasiveness of inappropriate institutional responses to its occurrence continues to raise serious concerns. The work of the Inquiry is a powerful reminder of the role of mental health services in addressing the needs of victims and survivors.

Concern has been growing about a cyclical pattern or ‘periodicity’ in mental health care over the past 300 years, in which large-scale policy decisions have been made, and then reversed, paying little attention to the particular needs of differing patient groups. Turner (1985) drew attention to the reckless course followed by psychiatry, and how the “discipline that has lost its way” (Lancet, 1985) may have done so owing to a poor grasp of its past history. In the movement towards community care, ‘difficult’ or the so-called ‘unrewarding’ (to use Scott's (1970) term) patients are a particularly vulnerable group (Aviram & Segal, 1973; Bachrach, 1980). Increasingly, community services are compelled to cater for less disturbed patients through being selective about whom they will accept. To a degree, forensic services on both sides of the Atlantic have partially filled the gap so created in service provision. For this and other reasons, it is difficult to make a general statement about the effectiveness of deinstitutionalisation and community care. To be more specific, there are basic conceptual difficulties in defining continuity of care and identifying subgroups for which it has different implications (Bachrach, 1981), and there are major methodological difficulties impeding an analysis of such a diffuse and fragmented provision. Scull's (1984) description of the overnight abolition of state facilities for juvenile offenders in Massachusetts in the US between 1969 and 1973 points to the impossibility of making a comparison ‘before and after’, when so much dissolution and decentralisation of services has occurred (see also Jones, 1982). A few model alternatives were described soon after the closures, and Bachrach (1980) has written about the dangers of generalising from model programmes, highlighting the differences between demonstration efforts and reality. It is proposed here that the difficult and offender population might act as a ‘litmus paper’ for the efficiency, or otherwise, of community care in general.

Ever since the clinical entity of “Folie à Deux” was first introduced (Lasègue and Falret, 1877), a great number of clinical and theoretical studies have appeared in the literature dealing with this relatively rare and interesting mental syndrome. In the English medical literature, up to date, 93 cases of “Folie à Deux” have been reported (Gralnick, 1942), a further 17 cases of “Folie à Trois” (Wolff, 1957; Dewhurst and Eilenberg, 1961), one case of “Folie Imposée à Quatre” (Ropschitz, 1957), one case of “Psychosis of Association” involving a mother and three sons (Page, 1942) and one case of “Folie à Quatre” involving four members of a family (Gralnick, 1943), have also been reported. I personally recorded one example of “Folie à Trois” at the Lebanon Hospital for Mental Diseases in 1947, involving a mother and her two daughters, and another interesting case of “Folie à Deux” in Baghdad (1961) involving a young boy who broke down under the influence of his spiritualist cousin. During the course of the boy's illness the cousin broke down herself into an acute delusional state. Both patients eventually recovered completely.

Hemispherectomy in man (ablation of the cortex, the underlying white matter and nucleus lentiformis) was performed first by Dandy (1928, 1933), later by Gardner (1939) and a few others, on adult patients suffering from large infiltrating tumours of the subdominant hemisphere, with one exception (Zollinger, 1935). It was carried out by McKenzie (1939) apparently on a patient suffering from infantile hemiplegia with epilepsy. Krynauw (1950a, b) began systematic work of this nature on cases of infantile hemiplegia with epilepsy and personality disturbances. Apart from its therapeutic value, in carefully selected infantile hemiplegics, in the hope of lessening or curing epilepsy, and exerting a beneficial influence on behaviour and further mental development, the comparatively small loss of functions after removal of one hemisphere is most remarkable.

Historically, in mediaeval times, the epoch of childhood was less clearly defined. If babyhood was survived, all but the most favoured children became little adults and a convenient source of labour. Instances of the barbarous treatment of children, infanticide, exploitation, starvation, flogging and mutilation, abound (Mause, 1976) and until comparatively recently these seemed to have caused little public reaction.

A case is described of a patient with Turner's mosaic (XO/XX) associated with anorexia nervosa. The cases described in the literature point towards the multifactorial aetiology of anorexia nervosa, emphasising factors other than the suppression of sexuality.

For many years, following the introduction of chlorpromazine in the 1950s, little progress was made in the discovery of new drugs for schizophrenia (Reynolds, 1992). Dopamine D2 receptor blockade was recognised as the only therapeutic target for antipsychotics (Creese et al, 1976) and the inevitable consequences of striatal blockade remained problematic. However, the strategies and stimuli for discovery of new drugs changed with the introduction of new, atypical antipsychotics in the 1990s. These include clozapine, remoxipride (now withdrawn), olanzapine, risperidone and sertindole (Kerwin & Taylor, 1996). The goal of antipsychotic drug development has always been to widen the therapeutic ratio between efficacy and adverse effects. These new drugs have in the main achieved this. However, which therapeutic targets these drugs employ remains a mystery, and this information is clearly important for future research into more selectively targeted agents.

For the treatment of general paralysis of the insane by induced malaria, the Board of Control, in consultation with the Ministry of Health, decided, at the end of 1924, to make an official arrange ment by which a pure strain of the benign tertian malaria parasite would be cultivated in mosquitoes, and would be made available for inoculation by mosquito-bites instead of by the direct inocula tion of blood from other patients. In consultation with the Mental Hospitals Department of the London County Council, the Horton Mental Hospital was selected for the work of pre paring and maintaining the strain of malaria in mosquitpes, and Col. J. R. Lord, C.B.E., Medical Superintendent of the Hospital, undertook the necessary arrangements in collaboration with Col. S. P. James, of the Medical Staff of the Ministry of Health. An isolated villa in the hospital grounds was selected as a treatment-block and laboratory; the Horton Mental Hospital authorities caused it to be mosquito-proofed and furnished, and the Ministry of Health supplied the scientific equipment of the laboratory. The Ministry also arranged that the routine laboratory work should be done by one of their laboratory assistants, Mr. P. G. Shute, under Col. James's supervision. I undertook the selection of cases suitable for treatment and their clinical care and management. The arrange ments were completed in April, 1925, and since that month 33 batches of infected mosquitoes have been prepared and utilized for the inoculation of more than 300 patients in 69 hospitals in England, Wales and Scotland.

Case records of 42 consecutive cases of obsessional states (seen between January, 1958 and April, 1962) were taken for detailed socioclinical analysis at the Psychiatric Clinic, Irwin Hospital, New Delhi. The case-taking, diagnostic, prognostic and therapeutic evaluations were made by the same psychiatrist, i.e. the author. The sample constituted only about 2 per cent. of the total new attendance of the clinic during the period.

Hydroxyzine hydrochloride (Atarax, UCB 4492) is a tranquillizer which has attracted much interest in the United States, where it has undergone a series of clinical trials with encouraging results. In order to test the claims of American investigators a trial of hydroxyzine was made on a group of psychotic and psychoneurotic patients in a large mental hospital. The effectiveness of hydroxyzine in controlling the tobacco habit was also tested by using volunteer nurses at the hospital. Their observations provided useful information on the subjective action and side effects of the drug. A small number of young children attending a local child guidance clinic were also included in the clinical trial.

In 1933 Potter expressed the opinion that a careful psychiatric study of patients in institutions for mental defectives “might demonstrate that schizophrenia in children is not as rare as is now generally believed.” Similarly in 1938 O. Lay wrote: “It is possible that many cases exist in institutions for the feebleminded, in which the disorders have been assumed to have existed from birth, and that a close examination would reveal that in the earliest years the patient's development was normal.”

The national cost of prescriptions for drugs for use in medical practice in the United Kingdome has risen progressively from £35,000,000 in 1949 to well over £100,000,000 a year now (Dunlop, 1965). The number of drugs taken by patients is vast, and the variety of drugs available for prescription is considerable. Prescribed in order to produce a specific therapeutic effect, few drugs, if any, are wholly free from the potential of producing undesirable side-effects. These vary from the trivial to the lethal, from the transient to the permanent. Methods for their accurate detection, qualitative evaluation and risk identification are vital prerequisites to therapeutic safety and refinement. Experimental techniques, using detailed observation on large samples of patients being treated by drugs, have been developed recently. A monitoring system which scans for side-effects of drugs represents a means whereby prospective and cumulative data on the frequency of occurrence and nature of these side-effects can accrue. This is referred to as drug monitoring.

Seizures induced by movement were first described by Gowers (1901), who considered them a variant of epilepsy. Several reports have appeared since then of attacks of choreo-athetoid movements precipitated by sudden movement (Lishman et al., 1962; Whitty et al., 1964; Stevens, 1966; Kertesz, 1967). The case described here is one of Lishman's et al's original group (Case No. 5); along with the movement-induced seizures he had developed over the years an increasing agoraphobia which had grossly restricted his activities. This paper reports on the successful treatment of this agoraphobia by ‘flooding’ and the associated amelioration of his movement-induced seizures.

In a random sample of 500 British women Coppen and Kessel (1963) found that certain menstrual symptoms—those of the premenstrual syndrome—i.e. depression, irritability, swelling, as well as menstrual irregularity, were positively correlated with Neuroticism on the Maudsley Personality Inventory. In a further study on the prevalence of menstrual symptoms in psychiatric patients (Coppen, 1965), a high incidence of menstrual symptoms was found in all groups, particularly neurotic women. Both these surveys were conducted by means of a menstrual questionnaire completed by each woman. This approach allows different groups to be investigated and compared, using a standardized measuring instrument. The purpose of this investigation was to see if cultural factors have any influence on the prevalence or severity of menstrual symptoms by administering a translation of the menstrual questionnaire to a sample of Spanish college students.