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.

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.

During the 1950s, epidemics of an illness which came to be known as Benign Myalgic Encephalomyelitis were reported from many different parts of the world. Fourteen such epidemics have been reviewed by Acheson (1959). As each fresh outbreak was reported several curious features began to emerge. No virus or other aetiological agent could ever be incriminated, in spite of strong evidence for an infective origin. The illness showed a strange predilection for young women, particularly nurses, and several epidemics occurred in association with poliomyelitis. And though muscular weakness and other neurological disabilities were often severe, objective evidence of damage to the central nervous system was usually conspicuously absent. Indeed, in comparison with other forms of encephalomyelitis the illness seemed mild, even trivial, yet those affected often suffered repeated relapses and exacerbations for many months or even years, and were always curiously slow to regain their former vigour.

The recent proliferation in mental hospitals of industrial units has created a need for some system of reporting on the work done by patients undergoing treatment in them. This paper is based upon four years experience of using a particular report form, provides some data about the validity and reliability of the form, discusses its shortcomings and concludes with a recently amended version of the form which it is hoped will be superior.

Working in a rehabilitation hospital (Morgan et al., 1965) for long-term psychiatric patients, many of them chronic schizophrenics, the author has been struck by the extent to which some of them are ignorant of the names of other people. This ignorance has been observed in formal therapeutic group situations, at formal interview, and in informal conversation. Whatever the situation may be, such ignorance hampers communication and causes socially incompetent behaviour on the part of the patient.

The great changes that have occurred in mental hospitals over the last fifteen years due to improvements in treatment of both acute and chronic psychiatric illnesses are reflected in the dramatic running down of the long-stay patient population. The Ministry of Health (1961) and Tooth and Brooke (1961) envisaged a continuing fall in the number of beds for psychiatric patients, so that by the mid 1970s these would have been reduced by nearly 50 per cent. from their 1960 figure (3·4 to 1·8 per thousand population). This prediction has been criticized because it was considered too optimistic, while the implication that the mental hospital, as we know it today, might cease to exist has provoked controversy.

In view of the increasing demand for the in-patient care of old people in Essex, a psycho-geriatric unit was set up at Severalls Hospital, Colchester in 1960 to provide a comprehensive service in its catchment area. The organization of this unit has been described by Whitehead (1966) and that of the day hospital by Haider (1967).

Few with relevant experience would dispute the common observation that a striking change for the better has taken place in the behaviour of long-stay patients in British psychiatric hospitals over the past fifteen years.

This enquiry is part of a wider investigation into the characteristics of children attending special schools for the educationally subnormal in South Wales. Seven local authorities are co-operating in the project, and they have made available records of children attending the eight special schools that they maintain. Two residential schools are provided by four rural authorities and six day schools are provided by three urban authorities. The characteristics of the population of 801 children who were attending the eight schools at the time of the enquiry have been reported previously in this Journal (Williams, 1966).

This investigation is part of a larger comparative study of Edinburgh primary school children referred to a psychiatric department with behaviour disorders and of a matched control group of non-referred children.

Richter (1960) reviewing knowledge about biological “clocks” in medicine and psychiatry, emphasized the incidence of 48-hour cycles of physical and mental symptoms. He considers that the mental symptoms are not specific and can be manic depressive or schizophrenic. Menninger-Lerchenthal (1960), in his book on periodicity in psychopathology, devoted a section to 48-hour rhythms and lists references to 48-hour cycles in the literature.

Since it was first described by Mannheimer, Pakesch, Reimer and Vetter in 1952 megaloblastic anaemia has come to be recognized as an occasional complication of anticonvulsant drug therapy. More recently a disturbance in folic acid and vitamin B12 metabolism has been observed in many non-anaemic drug-treated epileptic patients (Hawkins and Meynell, 1958; Klipstein, 1964; Malpas, Spray and Witts, 1966; Reynolds, Milner, Matthews and Chanarin, 1966a). Reynolds et al. (1966a) found megaloblastic haemopoiesis in 38 per cent. and subnormal serum folates in over 75 per cent. of a series of 54 out-patient epileptics. In addition, serum vitamin B12 levels, though still within the normal range, were significantly lower in the megaloblastic group of patients than in controls. They suggested (1) that the anti-folate effects of phenobarbitone, phenytoin and primidone may be related to their therapeutic actions, and (2) that prolonged drug-induced disturbances of folate and vitamin B12 metabolism may be responsible for certain side-effects, particularly mental symptoms. The latter possibility is supported by the increasing recognition of psychiatric illness due to vitamin B12 deficiency in the absence of anaemia or subacute combined degeneration of the cord. (Langdon, 1905; McAlpine, 1929; Holmes, 1956; Smith, 1960; Edwin, Holten, Norum, Schrumpf and Skaug, 1965; Strachan and Henderson, 1965).