Although depression is well known as a sequel to influenza, mania is not. We describe a patient with a severe psychotic illness who first showed features of a confusional state but then developed a manic psychosis. The occurrence of functional affective psychoses during or following systemic physical illness has been well described (Bonhoeffer, 1909; Kraepelin, 1921; Kiloh, 1961; Post, 1965), but the nature of the relationship has never been clear. In some instances, the physical illness may simply act as a form of non-specific stress precipitating the mental disorder; evidence for a more direct patho-physiological relationship has been lacking. When, in addition to a background of physical illness, a patient shows disorientation and clouding of consciousness together with signs of a manic psychosis, the diagnostic problem is especially difficult, particularly so since a confusional state can occur as part of a severe manic illness (Maudsley, 1895; Kraepelin, 1921). Conversely, hypomanic symptoms can occur in an organic psychosis (Bonhoeffer, 1909).

‘The Samaritans' were founded in 1953 to help ‘the suicidal and despairing’. As with similar lay agencies abroad, their growth in the past ten years has been vigorous; they now have more than 120 branches in the United Kingdom and these branches attracted over 50,000 clients in 1969. The Samaritans' aims have been described in detail by Fox (1968), but their most important aim is still the prevention of suicide. Their success in attracting the suicidal and preventing their subsequent death must therefore be the criteria of their effectiveness.

‘Psychogenic infertility’ refers to the state of childlessness in which psychological factors play an aetiological role. Use of the term ‘psychogenic’ implies that there is a reluctance or an ambivalence on the part of one or both partners towards conception. There is a considerable literature on psychogenic infertility, which has been reviewed elsewhere (Noyes and Chapnick, 1964; Mai, 1969). Although much of this literature is conflicting and inconclusive, it does suggest an association between disturbed sexuality and infertility in the female. Such a causal relationship might be mediated by two types of mechanism.

Hormone treatment for impotence and impotentia ejaculandi (delayed or absent ejaculation in the presence of normal erections and desire) (Johnson, 1965) is based on two assumptions: namely—that (1) potency in the male is androgen dependent and (2) impotency is due to relative androgen deficiency (Miller, 1968; Margolis et al., 1967; Sobotka, 1969). The synthetic preparations most frequently used are methyl testosterone, various esters, including the propionate, deconate, enanthate, etc. (Tuthill, 1955; Kupperman, 1967) and more recently a number of testosterone- ‘aphrodisiac’ combinations (Margolis et al., 1967; Cooper et al., 1971, etc.). Despite some claims of therapeutic success for the various regimes, the administration of exogenous hormones has several pharmacologic disadvantages. For instance methyl testosterone, which has to be taken sublingually or bucally, may be associated with severe toxic effects such as cholestatic jaundice, etc. (Goodman and Gilman, 1965). Parenterally administered testosterone esters, although less toxic and more certainly absorbed than methyl testosterone, have all the drawbacks of the intramuscular route; also their rate(s) of tissue release may not be optimal for metabolism. Additionally, all these synthetic compounds may inhibit endogenous testosterone formation and spermatogenesis by suppressing pituitary gonadotrophins. Long term administration may result in Leydig cell inactivity and even disuse atrophy. Recently Harkness et al. (1964, 1968) have observed that clomiphene (Fig. 1), a non-steroid triethylene derivative which in females stimulates the anovulatory ovary to secrete oestrogens (Bishop, 1970), significantly raised the levels of urinary steroid metabolites, including testosterone, in a proportion of ‘normal’ and corticosteroid deficient males. This unexpected testosterone elevating effect suggested its possible ‘experimental’ use as an alternative drug treatment in impotence. Accordingly a limited pilot study on five ‘primary’ (non-organic) impotent males was conducted: its main aims were (a) to assess the potential clinical utility of the drug and (b) to study its effects on the ‘pituitary-testes-axis' as reflected by plasma testosterone levels.

The tricyclic antidepressants are established in therapy but not in mode of action. Effects on mouse or rat brain of single and relatively enormous doses provide the basis for theories. Yet it may be inferred that the clinical use of tricyclic antidepressants relies upon an induction of brain changes on a time-scale of weeks. Studies of tricyclic drug actions upon human brain physiology are as scanty as are easily-measurable human brain functions. Electrophysiological techniques, however, can conveniently be applied during one principal brain-state, namely sleep, when there is a relative freedom from uncontrollable extraneous variables.

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).

Venables (1969) has suggested that a disturbance of lateral balance might be found in schizophrenia. Since this balance may be reflected in the hand dominance shown by the individual an investigation into the handedness of schizophrenics was carried out.

It is widely believed that tricyclic antidepressants such as imipramine bring little benefit for ten days, that three or four weeks are needed to be sure, and that five or six weeks are needed to get the patient really back to health. Why should it take so long? Is it even true? If true it seems remarkable that such a challenge should have been largely ignored by theorists content to rest their arguments upon acute experiments with animals.

Manic-depressive psychosis is characterized by severe swings of mood, which may be depressive, hypomanic or manic in type: occasionally a circular form is seen, with successive mood fluctuations in both directions in the same individual. Kraepelin indicated the frequency of these various types (depression alone 48·9 per cent, mania alone 16 6 per cent, circular 34·5 per cent), but also emphasized how difficult it is to predict the precise course of the disease in any individual patient. He stated: ‘we cannot speak of even an approximate regularity in the course of the disease’, and ‘the kind and direction of the attack and the intervals do not by any means remain the same in the individual case’ (Kraepelin, 1921).

Hurd in 1888 described cases of mania, melancholia, folie circulaire and attempted suicide in mental defectives. Ireland in 1898 described three ‘imbecile lunatics’ who were ‘clear cases of melancholia’, and quoted an earlier physician, Wells, who in 1845 had seen ‘attacks of mania in cretins, as well as a peculiar suicidal form of this affliction, which prompts the wretched maniac to attempt self-destruction by throwing himself into the fire’. Clouston (1883) considered that ‘congenital imbeciles may have attacks of maniacal excitement or of melancholic depression—in fact are subject to them’. Kraepelin (1896, 1902) took the view that ‘imbecility may form the basis for the development of other psychoses such as manic-depressive insanity, the psychoses of involution and dementia praecox’. Gordon (1918) stated that mental defectives suffering from depression rarely express ideas of guilt or thoughts of suicide; manics lacked ‘quickness of comprehension of wit or humour or sarcasm’. He noted that depression was more common than mania and that recurrences tended to run true to type. Prideaux (1921) accepted that manic-depressive psychosis could occur in high-grade mental defectives, and drew attention to the increased incidence of conversion hysteria in patients of low intelligence. Medow (1925) observed that mental defectives could manifest all the types of mental illness seen in people of normal intelligence but in the defective mental illness had a silly, fantastic, nonsensical colouring. Neustadt (1928) put forward the view that the typical psychoses of the mental defective were acute episodic states of excitement.

As part of an investigation concerned with investment by both hospitals and local authorities in mental health a number of analyses were made of various published statistics relating to costs and other operating characteristics. In the particular case of spending in mental subnormality hospitals what emerges is a pattern of such surprising variability that it was felt worthwhile presenting the information. It would appear that this particular crude analysis has not been pursued previously despite the existence of the great mass of cost statistics collected, processed, published and circulated within the Health Service. As the Service spent £39·1m. on these hospitals during the fiscal year 1968–69 one might have expected this comparative cost information to have been used in any planning process, particularly when, as will be seen, the magnitude of the variability is so considerable.

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).

Kraepelin (1896, 1902) believed that approximately 7 per cent of cases of dementia praecox arose upon the basis of imbecility. He also suggested that ‘certain forms of idiocy with developed mannerisms and stereotypies might be early cases of dementia praecox’, and proposed the term ‘Pfropfschizophrenie’ to denote ‘eine besonders früh entstandene Schizophrenic’ (a schizophrenic psychosis of particularly early onset). Though he later modified his views and agreed that the rhythmic movements seen in some idiots did not in fact signify dementia praecox, he continued to believe that dementia praecox beginning in the first decade could produce 'states of weakness … regarded as imbecility or idiocy’.

The classification of depressive illness has long been a source of controversy in British psychiatry. In particular, phenomenological and statistical studies have failed to agree about the existence of a valid distinction between ‘endogenous' and ‘reactive’ depression (Carney, Roth and Garside (2); Eysenck (3); Kendell (7); Maxwell (9)).

In 1966 Slater proposed a computational model for distinguishing polygenic inheritance and the effects of a single dominant gene. For a single dominant gene with diminished penetrance, affected relatives should be found predominantly on either maternal or paternal sides. He further proposed that to support a dominant gene hypothesis the ratio of unilaterally ill pairs to bilaterally ill pairs of relatives should exceed 2:1. ‘Unilateral pairs' means that there have been two or more ill relatives on either paternal or maternal sides; ‘bilateral pairs' that there has been at least one ill relative on each side.

Ketamine (‘Ketalar’), a recently introduced phencyclidine derivative, is a dissociative anaesthetic agent with a number of unique and useful properties. Its most important advantages are the relatively good preservation of the swallowing and cough reflexes, and its rapid absorption following intramuscular injection. In addition, it has little depressant effect on respiration, while blood pressure is usually raised (Morgan et al., 1971; Bovill et al., 1971). It also has the effect of increasing muscular tone, thus preventing airway obstruction by the tongue.

The Recruitment of Psychiatrists Every teacher of psychiatry bears a dual responsibility. Not only must he inculcate the essential principles of his subject into medical students, irrespective of their eventual choice of career within medicine, but he must also help recruit into psychiatry a sufficient number of doctors to develop the psychiatric services of tomorrow. Moreover, the quality and personal attributes of these recruits must be such as to do credit to the profession.

We have recently had the opportunity to investigate clinical and behavioural characteristics of a pair of 17-year-old twin boys who were discovered to have the XYY karyotype (18). Since these twins, known to this department since infancy, had been studied at the age of three, early direct findings as well as retrospective data are available regarding their symptoms and development.

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.