The Disabled Persons (Employment) Act of 1944 set up a national register of disabled persons and facilities for their industrial rehabilitation. The Industrial Rehabilitation Units of the Ministry of Labour which were provided for by this Act were described and their functions evaluated in the Piercy Report (1956). The broad scope of present concepts of rehabilitation is fully reviewed by Vaughan Jones (1961) and will not be discussed here.

This investigation arose from the clinical observation that there are certain people who are psychiatrically very ill yet live at home or in the community, whilst others no less disturbed are referred to mental hospitals and kept there for varying periods. Although several excellent studies have been done on chronic schizophrenics and other serious mental illnesses after discharge from hospital, no study has been found in the literature concerning chronic cases who have never been hospitalized, and it was hoped that a careful investigation of such patients and their circumstances, i.e. social and economic conditions, the organization and attitudes of the family, the psychiatric condition of the patients, etc., would lead to a better knowledge of community care.

Androgyny is an expression of relative masculinity and femininity in body-build. Tanner (1962) states “Androgyny can be perhaps best measured by means of scales constructed so as to give the best discrimination between men and women, and the simplest of such scales measures a masculinity score as 3 Biacromial—1 Bi-iliac diameter. This score gives men a mean of around ninety-three units with a standard deviation of about five, and women a mean of about seventy-eight with a similar standard deviation”.

It probably goes without dispute at the present time that the precise content of a schizophrenic's thought, like that of anyone else, is derived from experience. Even the remarkable mélange of Schreber's memoirs could in large part be traced to his childhood experiences (Niederland, 1959). There is generally little doubt that the exact form and the course may be determined by age and experience; the effects of genetically determined intellectual endowment are uncertain (Elsässer, 1952; Rosenthal, 1963). The very occurrence of schizophrenia as a clinical phenomenon challenges the investigator, and there are many who question whether experience alone could result in schizophrenia in any and all human beings. They ask rather to what extent and by what mechanisms is the occurrence of schizophrenia determined by genetic factors.

After 25 years there is still considerable disagreement surrounding the indications for electro-convulsive therapy (E.C.T.). This is a particular problem in the treatment of depression, both because of the controversy over the division of depression into endogenous and reactive illnesses and because of the increasing use of the antidepressant drugs. These drugs will induce a remission in many patients, and will alter the clinical picture in others. As their use becomes still more widespread (Freyhan (1) has recommended that intensive imipramine treatment should be tried routinely before E.C.T. in all depressed patients) there may be further difficulties in the selection of depressed patients likely to respond well to E.C.T. Furthermore several recent reviews draw attention to a reduction in the use of E.C.T., and the lack of a consistent rationale for its use (2–4).

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.

The sheer volume of new drugs introduced into psychiatry within the past decade has created an urgency to get to the point as quickly as possible: Is Drug B better than A, and, if so, what about B and C? With some abatement of the tide of new compounds it becomes possible to look, not just for a quick answer, but at some of the conditions of the trial which determine the outcome.

The last twenty years have seen the rise and dominance in institutional psychiatry of a remarkable notion—“the therapeutic Community”. It is both an attitude and a method, a system of treatment and a battle cry, a charm and a password. I have been fortunate to take some part in applying this notion to one part of the field of inpatient psychiatric treatment and have attempted, while doing so, to study the effects of what we did.

This paper describes the preliminary clinical testing of a new sedative drug, and also explores the feasibility of using a single-patient, self-controlled and recorded design in psychiatric drug trials. Hogben and Sim (1953) demonstrated a form of drug trial which emphasized intra-subject fluctuations and their control. Recently, Shapiro (1963) has argued the usefulness of a similar approach in fundamental, clinical research. However, the single-patient drug trial appears not to have been widely used in psychiatry, although several writers, e.g. Shepherd (1963), have indicated its possible advantages.

Depression is the commonest of mental illnesses and fortunately it has a better outcome with treatment than any other psychiatric condition. It shows itself in a variety of guises, and as there is no universal formula for treating the different types, a classification is essential. During the past ten years the arrival of the tranquillizers and particularly antidepressants has revolutionized our view of depressive illness, yet we are still using terms which are purely descriptive, determined by administrative needs long forgotten, or loosely related to aetiology about which we still know little. The time has come to link the classification of depression with rational treatment, but before offering a scheme to do this, a brief consideration of the inadequacies of existing terminology may help to explain the need for a new scheme.

Writer's cramp (scrivener's palsy, mogigraphie, graphospasms, cheirospasmus, crampe des écrivains, dyskinésie des écrivains, graphic dyskinesia, Fingerkrampf, Schreibkrampf, etc.) is one of a large group of functional motor disorders, known as “occupational neuroses and cramps, craft neuroses, professional neuroses, crampes fonctionelles et professionelles, spasmes professionelles, impotences professionelles, Beschäftigungsneurosen, Beschäftigungskrämpfe”, wherein there is a specific impairment of a learned motor skill. Generally, writer's cramp is characterized by muscular spasm, inco-cordination, and discomfort, variously described as fatigue, weakness, stiffness, or pain when attempting to write. Occasionally, there is an accompanying tremor or jerking of the involved upper limb. There is said to be great variability in the detailed clinical picture. Writing may be difficult or impossible, but outside the act of writing the symptoms generally disappear. Often there are fluctuations within a chronically progressive course but the condition may arrest at any stage of its development.

Despite the apparent relevance of studies of the effects of “perceptual isolation” of the kind reported by Bexton et al. (1954) to some of the problems of abnormal psychology and psychiatry, there seems to be a dearth of plausible hypotheses Unking the consequences of this form of deprivation with clinical, disorders. A good deal of experimental evidence from deprivation experiments has been brought together by Solomon et al. (1961) in the report of a symposium held at Harvard Medical School in 1958. In 1959, however, yet another symposium was held at the American Psychological Association's annual meeting in Cincinnati which it was still found possible to entitle “Sensory deprivation: facts in search of a theory” (see Freedman, 1961; Riesen, 1961; Held, 1961; Teuber, 1961; Hebb, 1961).

Patients with somatic symptoms who fear serious organic disease are frequently encountered in medical practice. Chest pain and palpitation for example may give rise to concern about heart disease, and abdominal pain to fear of cancer. Every case warrants careful consideration, including examination and investigation where necessary. As a result, some will be relieved both of anxiety and symptoms by simple explanation and reassurance, if their fears were ill-founded or misplaced. The outcome may not be so favourable in others, also free of physical disease, who may need expert psychiatric help. Davies, B. (1964), reviewing the literature, reported a mean incidence of 27.3 per cent. of medical out-patients with purely psychiatric illness, and a further 10–40 per cent. with mixed organic and psychiatric conditions in those attending general hospital clinics.

Reports coming from Central Australia draw attention to mental instability in the Aborigines who live between Hart Range and Lake Nash near the Queensland border (Fig. 1). Well-informed persons—welfare officers, nursing sisters, an aerial medical officer (“flying doctor”) and cattle station managers—are firmly of the opinion that these Aborigines show an undue amount of instability and frank mental illness. Furthermore, South Australian mental hospital records reveal that in recent years, many Aborigines of this region have been referred to Adelaide for treatment of unusual psychoses. Statistics of the sort available in more settled areas are lacking. There is no local psychiatric service to keep a register of disorders occurring in this population. But the local impression of mental instability is strong and the questions it raises are clearly important. Is there a localized instability in Central Australia ? If so, what is its distribution? What is its nature? Is its cause to be found in constitutional peculiarities of the people ? Or in environmental stresses that they are undergoing in their cultural transition ?

The assessment and measurement of the mental state in patients suffering from a depressive illness is important both in clinical psychiatry and in research. Clinical assessment by an experienced psychiatrist, even when it is quantified on the basis of a rating scale (e.g. Hamilton's Rating Scale for Depression) has the disadvantage of being dependent on the skill of the rater and on his clinical bias. These drawbacks make it somewhat difficult to compare meaningfully results obtained in different investigations.

Variations in the attitude of psychiatrists to schizophrenia range from the precise and confident pronouncement of Sargant and Slater (1963) “Chlorpromazine seems to bring the schizophrenic process to a rapid halt, and to lessen the chance of chronicity and deterioration of personality” to the fundamental doubts expressed by Szasz (1957) “The problem of schizophrenia, which many consider to be the core-problem of psychiatry today, may be truly akin to the ‘problem of the ether‘. To put it simply, there is no such problem.” The literature abounds in varying, conflicting and even irreconcilable treatment suggestions. One has only to compare the physical treatment schedules recommended by Sargant (1963) with the advocacy of psychotherapy put forward by Arieti (1959); or the views on drugs of Kalinowski (1958) with the Hordern and Hamilton (1963) assertion that drug results have not been shown to be superior to the effects of “moral treatment” of a century ago. Similar comparisons in the social field might be made between the views of Hamilton and Salmon (1962) and Hamilton (1964) on sheltered workshops and the difficulties of rehabilitation programmes demonstrated by Catterson et al. (1963).

Some years ago, we reported a study of the illness experience of children according to the presence or absence of a psychoneurotic condition in each of their parents (Buck and Laughton, 1959). It was stated to be part of a larger study of family patterns of illness, including that of possible similarities in the psychiatric histories of husbands and wives. Although the latter was investigated with rather interesting results the work was not published upon completion because we hoped to add to the data. In the last few years, interest in this subject has been revived, particularly by the work of Pond et al. (1963) and Kreitman (1964). It now seems desirable that our results should be published because of their interesting relationship to those of the more recent investigations.

Mumps, or epidemic parotitis, is caused by a filterable virus and is characterized by temporary enlargement of the parotid and sometimes other salivary glands and by the occurrence of complications, of which orchitis in adults and in post-pubertal boys is the most common. The virus is pantropic causing central and peripheral nervous complications in many cases. In civilized countries the disease is endemic but local outbreaks occur. One such outbreak occurred in Bristol during 1964, in the spring, the season when mumps is most prevalent. The case that is described here formed a part of that particular epidemic. Before proceeding to the case report the literature on the psychiatric complications of mumps will be discussed.

St. Wulstan's Hospital, Malvern, opened in November, 1961. It is the first hospital in Great Britain to be given the specific function of rehabilitating selected chronic psychiatric patients from other hospitals. The original plans for its use were made by the Mental Health Services Advisory Panel of the Birmingham Regional Hospital Board. In 1959 this panel was confronted with overcrowding in the Board's twelve existing mental hospitals; it was offered the use of a tuberculosis sanatorium that would shortly be closing for lack of patients, and it was impressed by the results reported from other hospitals of giving chronic patients industrial work to do. Accordingly the panel formulated plans to reopen the former sanatorium as a psychiatric rehabilitation hospital. The execution and development of these plans are described in this paper.

Under the concept of constitution are subsumed the predispositions towards illness, and the resistances against illness, to which genetical make-up and environmental experience have contributed during the preceding lifetime of the individual. It is in that sense that “constitution” will be used in the rest of this paper. Old age provides a vantage-point of particular value for the study of constitution, since it is possible to examine in retrospect over a long span of time the changes and vicissitudes which have affected it.