In the United States considerable emphasis is at present being placed upon emergency psychiatric services. This is part of a national drive to provide a high level of care for the total population and not just those who can afford the services of private psychiatrists. Investigations have been conducted in various centres in the U.S.A., and subsequent discussion and documentation (e.g. 5) suggest that emergency care is best given by a centre which also provides full in-patient and out-patient services. This echoes and reinforces the recommendations of the “Community Mental Health Centers Act”, which promises Federal matching funds to American states setting up community mental health centres, provided the services are comprehensive. The term “comprehensive” is defined in some detail, and comprises in-patient and out-patient services, partial hospitalization (e.g. day-care), emergency services for 24 hours in the day, and consultation and educational services to professional personnel and to the community at large.

The rehabilitation of disabled mental hospital in-patients depends on changing the structure of the hospital itself. Remunerative and realistic employment plays an important part in this respect. Not only does it provide greater emotional satisfaction to the patients, it also enhances their status by changing their role from that of sick people to that of trainees in more normal habits of living and work. It is difficult to create an occupational programme which employs the large population of a hospital according to the patients' varying disabilities, inclinations and needs. It is unsatisfactory to provide occupation only for a small proportion of patients or for those who are easier to resettle. All patients (even those who do not appear disabled) need occupation designed to prevent incapacitating disabilities or to reduce their handicaps.

It has long been recognized that chronic brucellosis may present as a psychoneurotic illness, and this is well emphasized by Spink (1963) in Cecil and Loeb's Textbook of Medicine. However, presentation in the form of a psychosis is rare, and this is not mentioned in Spink's article, nor in a standard psychiatric textbook such as Mayer-Gross, Slater and Roth (1954). Dalrymple-Champneys (1960) described a series of 1,500 cases of brucellosis; only two of his patients had delusions and hallucinations. Hobbs (1931) described the case of a woman of 56 who developed delusions of persecution and believed her food to be poisoned. This latter symptom was also shown by one of the patients in Dalrymple-Champneys' series, and the same complaint occurred in my patient. Although a very rare cause of paranoid illness, the recognition of brucellosis is important so that appropriate treatment can be instituted.

The conduct of this survey has brought home to us the great diversity which exists in the amount, content and methods of teaching psychiatry in U.K. medical schools today. No two schools are quite alike in the type of staff facilities, in the allocation of teaching time in the several years of the course, or in the persons available to act as teachers. After two trial runs, we evolved a schedule of inquiry which has enabled us to compare schools in a number of respects in which reasonably reliable and quantifiable data were available. This report necessarily concentrates upon those aspects in which the various schools can be compared with each other: it does not do justice to the full detail of all the teaching given in any one school. In particular, we have deliberately confined our attention to teaching which is given to all students, whether they take advantage of it or not. Except for some observations on organized periods of elective study, we have not dealt with the extra opportunities which arc available in a number of schools for students who go out of their way to seek additional experience in psychiatry. Our schedule of inquiry was discussed by one of us personally with the psychiatrist responsible for teaching in every school except one—a London part-time teacher who remained obdurately “too busy” to comply with this request. It was found necessary, in the majority of cases, to supplement our interview and the schedule return by further inquiries; in a few particulars, and in respect of certain schools, we are still left in some uncertainty as to the accuracy of the information given to us. This report is submitted, however, as the best approximation possible within the limitations of our survey.

The observation of a higher incidence of sex-chromosome abnormalities amongst patients in mental deficiency and subnormality institutions than in the general population (Maclean et al., 1962; Court Brown et al., 1964) suggested that a sex chromatin survey of a theoretically related chronic psychotic population might be of interest. Mott (1919) observed a high frequency of testicular atrophy in dementia praecox, particularly in patients dying in early adolescence, and Forster (quoted by Mott, 1919) reported on the ovarian findings in similarly affected women. Hemphill et al. (1944) found a high incidence of testicular atrophy in a series of ninety male schizophrenic patients.

The demonstration of either the association of a genetic marker and primary affective disorder, or linkage between a genetic marker and primary affective disorder would provide incontrovertible evidence for a genetic factor in primary affective disorder. Disease association and linkage are two separate processes. Linkage is said to occur if two genes, each responsible for a separate trait, are on the same chromosome and are close enough together that they assort in a dependent fashion. In any single family the physical proximity of two genes on the same chromosome makes it likely that the characteristics of both genes will be found in a single individual. Association, on the other hand, occurs when two genetically separate traits have a non-random occurrence in a population. Association of a disease with a specific marker may occur fleetingly on the basis of linkage. This kind of association occurs only for a few generations, so that when enough generations have passed and enough crossing over has occurred between chromosomes the association disappears. Therefore, linkage produces no permanent association in the population, but may only be found within the family. The mechanism of association is, therefore, not that of linkage, but may be more likely explained by pleiotropic effects of a single gene.

Educational objectives in medical school training used to be stated in global terms, seldom possible to implement and still more difficult to test (Objectives of Medical Education, 1953). The student's training hopefully was required to help him “to respect the rights and dignities of patients”, or towards “expecting to be a student all his life”. How to evaluate the presence or absence of these qualities after training was not conveyed either by the form or by the sometimes frankly inspirational language in which the objectives were stated.

An analysis has been reported of the in-patient case-load of a comprehensive psychiatric department (Queen's Park Hospital, Blackburn) for the twelve months ending 28 February, 1961 (Silverman, 1961). This analysis showed that a department of 99 beds was coping with virtually 95 per cent. of the total in-patient problem from a population of approximately 250,000. However, the criticism has not uncommonly been made that, although a department of this kind might appear to function with reasonable success at the outset, the nature of the psychiatric case-load is such that, sooner or later, an excessive number of beds would become blocked by long-stay patients and the service would become unworkable in its original form. It was therefore decided to report and analyse admissions and discharges over a much longer period, and the statistics for the four years ending 31 December, 1965, were utilized for this purpose.

Pregnancy and the post-partum period are generally regarded as maturational crises equal in importance to those of adolescence and the menopause. Stresses undergone during this period include (a) endocrine changes, (b) activation of unconscious psychological conflicts pertaining to pregnancy and (c) the intrapsychic reorganization of becoming a mother. In light of this, it seems likely that clinically significant interactions of psychosocial and endocrine factors will be found in the aetiology of these disorders. The first month post-partum shows the greatest incidence of overt mental illness (7, 9), and this has led many to relate this disturbance to the termination of placental function and the metabolic and/or endocrine changes accompanying this.