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1. A follow-up of 42 long-stay schizophrenic men, 24-52 months after discharge from the same mental hospital rehabilitation unit is reported. 2. Thirty (71 per cent.) had not been readmitted to a mental hospital 2 years after discharge, and these were arbitrarily defined as Successes, the rest as Failures. Re-admissions took place at a fairly constant rate throughout the 2-year period, and without exception followed a serious relapse of schizophrenic symptoms. Only one re-admission occurred after 2 years in the community. 3. Re-admissions could not be related to social factors such as type of living group, or certain obvious social stresses such as death of parents, loss of lodgings or job. 4. There was a significant association between Success and regularity in taking maintenance phenothiazine therapy, but it was pointed out that this need not be a causative relationship and that larger scale studies were necessary to confirm or refute this finding. 5. A high level of employment was achieved throughout the group, and using the criterion of regular work for at least three-quarters of their time in the community, or before a first re-admission, the Successes (90 per cent.) and the Failures (75 per cent.) showed little difference in performance. 6. Just over half the Successes (57 per cent.) were also rated as "Nearly Normal" in social behaviour at home. The remainder (43 per cent.) were rated as "Moderately Disturbed", or in 2 cases, "Severely Disturbed". 7. Six of the 11 "Moderately Disturbed" patients also appeared to cause moderate hardship to the living group, and both "Severely Disturbed" patients caused severe family hardship. 8. Attention was drawn to what appeared to be the more important shortcomings of the community after-care provided for the patients, particularly a greater need for sustained support of patients' families. 9. These results have been briefly discussed, and it has been considered more important to set the results accurately in their background of type of hospital rehabilitation programme, the extent to which the series was representative of one hospital's rehabilitatable long-stay schizophrenic population, and the community aftercare facilities provided, rather than to attempt to generalize from the results of one small-scale study. 10. The value of the pre-discharge rehabilitation experiences of these long-stay schizophrenics seemed almost entirely in terms of minimizing their secondary handicaps.

A detailed description is given of a social rehabilitation programme for long-stay mental hospital patients, with evaluation of a six month period of operation. It was found that changes instituted in drug therapy on this group were minimal, and that the level of functioning as measured on two nursing rating scales showed significant improvement over this period, enabling a number of these patients to be successfully discharged to the community. In view of the long period of previous hospitalization and minimal changes in drug therapy, the conclusion must be drawn that the relevant factor in producing the improvement was the milieu. It is therefore suggested that this type of milieu is one which may suitably be used for the effective rehabilitation of this type of patient.

SYNOPSISA cohort of patients from Camberwell, who had been in psychiatric hospital for one year or more on 31 December 1964, is described. The attrition rate for this group, and the accumulation of ‘new’ long-stay patients from the area since that date, are analysed, and compared with published data from other studies. In the light of the resulting overall decrease in the long-stay population with time, possible trends in the future can be considered.

A token reinforcement programme was set up to increase verbal participation in a weekly quiz for a ward of 38 male long term psychiatric patients. Response rates were measured and it was found that the amount of participation increased markedly when reinforced but returned to the original low level when reinforcement was discontinued. The study demonstrates that a token reinforcement procedure is effective in increasing the patients& verbal participation in a social activity.

It was my first intention to know the relation between Arakawa's reaction and the uric acid excretion. Animal experimentation reported in literature showed unanimously that animals fed-on B-avitaminotic food had an increased excretion of uric acid. Apparently healthy lactating mothers with milk negative to Arakawa's reaction are generally in a state of B-avitaminosis. If it is so, it will follow that Arakawa-negative mothers will excrete more uric acid per day than Arakawa-positive ones. This is the problem I wanted to solve. As it is, however, very difficult to collect whole day urine of these healthy mothers, I wanted to solve the problem indirectly. Lactating mothers whose sick infants had been admitted to our Department were made objects of investigation, because it was less difficult to collect their whole day urine and they might, as I thought, change their Arakawa's reaction during their more or less long stay at our Hospital. So I studied the relation of the change of Arakawa's reaction and the amount of uric acid excreted in 10 lactating mothers. When their Arakawa's reaction changed from worse to better, they were considered to have changed from worse to better with regard to their B-avitaminotic state. (This consideration was the natural result of a number of investigations from our Laboratory). The result was: 1. When Arakawa's reaction was positive, the amount of uric acid excreted was the smallest, and 2. in the case of completely or almost completely negative Arakawa's reaction, its amount was the largest. 3. And in the case of intermediate reactions, its amount was of intermediate values. It was thus highly probable that apparently healthy Arakawa-negative mothers, who are in a state of B-avitaminosis, would excrete a larger amount of uric acid per day than Arakawa-positive mothers. Besides, the following result was seen. Umemura2) of our Laboratory showed that Arakawa-positive mothers generally excreted a larger amount of urine per day than Arakawa-negative ones, and that specific gravity of urine was generally smaller in the former than in the latter. In my own investigation, when Arakawa's reaction improved, lactating mothers excreted generally a larger amount of urine per day and the specific gravity of their urine became smaller generally. What has been stated in the Summary will further be confirmed by the result of my own, which will be reported under the title: Influence of Vitamin B Administration upon Urinary Uric Acid Content and Arakawa's Reaction of Lactating Mothers.

Attitudes to discharge are examined among 58 long-stay schizophrenic patients by long informal interviews. Information was collected on their age, length of stay, employment level, degree of contact with relatives, degree of social withdrawal and severity of illness. Preference to leave hospital decreased significantly with length of stay, confirming previous studies. Attitude to discharge was more frequently correlated with the patient's degree of illness and of social withdrawal than with other factors. When the number of handicaps a patient had was compared with his attitude to discharge, a highly significant relationship was found: those with the fewest handicaps were the most willing to leave, though patients with many handicaps varied widely in their attitudes to discharge. Problems of methodology in attitude evaluation are discussed.

1. A psychiatric survey was made of 50 soldiers with prominent gastric symptoms but no relevant organic disease, who were in-patients at an E.M.S Neurosis Unit. 2. A control study was made of a series of neurotic soldiers, in whom gastric symptoms were inconspicuous or absent. 3. The gastric symptoms were generally vague in description and variable in character and combination. A few features, however, deserved notice, e.g. relationship to emotional stress and exertion. Gastric symptoms had been comspicuous in 86 per cent. of the "gastrics" before joining, and appeared to have become worse in 44 per cent. of these within three months of so doing. 4. Army efficiency in the gastrics had been much poorer as a whole than in the controls. 5. Many gross neurotic traits were evident in the family, past and present histories of gastrics and controls, but a number of these were much more prominent in the gastrics. 6. 74 per cent. of gastrics gave a history of gastric disorder in one or more members of the immediate family as compared with 5 per cent. of controls. 7. 74 per cent. of the gastrics had had satisfactory civilian work records. 78 per cent. of the were married and 70 per cent. of these appeared to have had happy married lives. They had adapted comparatively satisfacorily to fairly sheltered lives. 8. A markedly dependent attitude to life was present in 70 per cent. of the gastrics 9. Homesickness and inability to adapt emotionally to the condition of army life were the main precipitating factors in ultimate breakdown in both gastrics and controls. 10. A diagnosis of anxiety-neurosis was made in 68 per cent. of gastrics, and anxiety neurotic features were very prominent in a further 24 per cent. 11. The disadvantages of long stay in hospital and the part it played in our patients' histories are reviewed. 12. 80 per cent. of gastrics were recommended after treatment for discharge, as compared with 64 per cent. of all patients at our unit over a corresponding period.

SummaryThe treatment of juvenile rheumatoid arthritis is discussed. It is emphasized that there are two aspects of the treatment: 1) to suppress or stop the pathologic process in the connective tissue, and 2) to prevent deformities and contractures in joints and extremities during active phases of the disease, and to correct them at the initial stage. As splinting or bracing of inflamed joints is also often indicated in order to calm the process, a great part of the treatment will consist of conservative orthopedic measures. A long stay in hospital is inevitable.However, we must also realize that we have no causal therapy against the pathologic process, since the etiology and pathogenesis are unknown. Therefore R.A. is incurable directly. But on the other hand we can do much indirectly through improvement of the general condition. It is also possible through several different drugs to relieve the pain, facilitate the movements and give the sick child a better capacity to work and play. R.A. may not be cur...

In 1917, in Paris, during the first World War, I was studying in the tuberculosis dispensary of the Laennec Hospital, then directed by Dr. E. Rist. I was very young and inexperienced then, but the circumstances of the moment, as well as the association of a double curiosity in my mind—the study of physics and medicine—led me to think in 1918 of the possibility of fluorography, so as to obtain small documents of very low cost, permitting the x-ray examination at the dispensaries. After a long stay in Paris, from 1914 to 1922, I returned to Rio de Janeiro, where I intended to fully realize my career. The problem was that of the diagnosis of tuberculosis and of cardiovascular affections which had to be done in the early stages and on a large scale. I resumed in Rio, in the Superintendency for the Prophylaxis of Tuberculosis, newly created by Placido Barbosa, the experiments interrupted in Paris, and in 1924 I obtained some fluorographic negatives. However, it was still too early. I did not succeed in emerging from the experimental stage. But, already at that time, the miniature radiograph and its vast social application, seemed to me to be the only solution to the problem of the mass diagnosis of apparently healthy persons. At last, in 1935, I came back to systematic fluorography. The luminous slides of calcium tungstate, lens of 1-1.5 aperture, linear cathode tubes and the photographic emulsions of 28° Scheiner, included the necessary condition for the realization of an idea of my youth—the radiographic examination of population groups. I .constructed a frame in the shape of a truncated pyramid, fixing the camera in its smaller base, and at the larger one the fluoroscopic screen. The complete frame slid between four columns. It was the first micro-radiographic apparatus which I exhibited in 1936 to the Medical Society of Rio and Sao Paulo. The negatives measured 35 and 40 mm. The clearness and the contrast were good, obtaining a favorable report from the Brazilian Society of Tuberculosis, which recommended the adoption of the new method. In February 1937, I inaugurated the first Survey Center in the Rio Public Health Department, based on the 35 mm. fluorography; it was intended for social groups of apparently healthy individuals. In the same year the Central Navy Hospital and the Public Health

The census of all patients in psychiatric hospitals and units in England and Wales (Brooke, 1967) showed that the rundown of this inpatient popu lation, as forecast by Tooth and Brooke (1961), was being maintained in 1963. Since then other studies (Lancet leading article, 1969) have confirmed this continuing trend, although the rate of decline obviously varies from area to area. In the Birming ham Region, for example, the number of patients in residence per 10,000 population of the region was 21 at the end of 1968 as compared to 28 per 10,000 population at the end of 1958. These reductions are mainly due to the falling numbers of long-stay patients (those continuously in residence for at least two years), and for any such long-stay population it is important to study sep arately (1) the changing pattern of a standing popu lation selected at a given time; and (2) the extent to which new patients are accumulating. In a previous paper (Hassall, Spencer, and Cross, 1965) the authors considered in some detail the composition of the inpatient populations of Powick Hospital at the end of each of the years 1952, 1957, and 1960. These patients were followed up until the end of 1962 and annual rates of discharge and death for the three populations were compared. The purpose of the present contribution is to study the subsequent experience of patients admitted to the hospital over the 10 years 1956-65 and to estimate the annual rates of accumulation of 'new' long-stay patients and their contribution to bed occupancy. By combining results from the two enquiries, forecasts of long-stay hospital populations can be made. Important differences exist between localities in respect of the needs for inpatient psychiatric care, and it is important to conduct local studies which take account of as much relevant data as possible regarding the changing patterns of admission and discharge of patients.

1. The follow-up reports of ninety-one joints affected by rheumatoid arthritis and treated by synovectomy showed that seventy-three joints remained free of pain. Forty-nine out of ninety-one joints retained useful function after a period averaging three and a half years. 2. The average duration of the disease before admission was eight and a half years. 3. The joints causing most distress were selected for operation. Better results might have been obtained if these patients had received constitutional treatment, splintage and synovectomy earlier. Many of these patients had advanced disease which was continuing to advance at the time of their admission, in spite of previous treatment. Many accepted a trial of treatment in a long stay hospital as a last hope. 4. The return of forty-eight out of sixty-two patients to unassisted or nearly unassisted activity and the maintenance of this state in thirty-nine out of fifty-four shows that the success of the pilot scheme conducted in cooperation with Dr W. S. Tegner and Dr R. M. Mason of the London Hospital has been confirmed by further experience.

A treatment experiment in a ward of a Swedish mental hospital is reported. Twenty-seven women aged 47 to 80 years, who had been in hospital between 12 and 53 years, and were functioning at a very low level, were observed for 22 months. The treatment consisted of conventional habit training, including sociotherapy and pharmacotherapy. The results of the treatment were systematically measured from records of personal hygiene and ratings on a set of scales. Improvement was statistically demonstrated. Patients tended to deteriorate when the head nurse changed. A correlation analysis of all the variables used showed that a low level of functioning (including poor personal hygiene), advanced stage of illness, long hospitalization, lack of contact with relatives, and low degree of mobilization were associated together. On the other hand, age was not correlated with these variables. According to a multiple regression analysis based on five representative variables, the inactivity-isolation syndrome was most associated with the criterion of improvement, whereas the hyperactivity-disintegration syndrome, scores on habit scales, and length of stay added little extra predicting power. The results are discussed in connection with previous studies of chronic schizophrenia.

An inspection of the final column of comparative costings in Tables I and II indicates that the owner of the outside factory would definitely find his 10 operators employable. The deficit for the sheltered factory, employing 30 patients, amounts to £1,070 per year but this figure includes the salaries of two charge nurses (£1,500) who would have to be employed irrespective of whether the patients were working, thus converting this deficit into a small profit. Further, mental patients are now entitled, as the physically disabled are, to be registered as disabled persons. Facilities have now been created whereby suitable mental patients who can perform roughly a third the amount of work of normal workers over a normal working week, can be approved by the Ministry of Labour and Local Authority and then be paid an industrial wage (i.e. £8 5s. Od. for men and :6 3s. 9d. for women). Thus it becomes possible to provide permanent sheltered realistic work for the mentally disabled. With these terms of reference therefore, one can say that long-stay mental patients are employable at no cost to the hospital. What is equally important, however, is that such a unit offers opportunities of complete rehabilitation with placement of a certain percentage of these patients in outside employment. What is also important is that such a unit provides excellent facilities both for assessing patients' abilities based on their actual work performance, and of providing learning situations in which patients may increase their abilities and reduce their disabilities or attitudes towards them. The problem is less to train the long-stay mental patient in a particular craft or skill than to develop the correct habits and attitudes necessary if resumption either of former types of occupation or training for new skills is to be accomplished. Finally, the success of the unit can to some extent be judged by the fact that in the last 12 months, 18 long stay patients have been successfully placed in various types of outside employment quite unrelated to the work carried out in the hospital factory.

This paper reports an investigation of the extent to which long-stay psychiatric patients are handicapped by an ignorance of other people's names. 68 representative patients and 29 non-patients were invited to name 10 staff from descriptions, 20 staff from photographs and 20 patients from photographs. There was a very wide range of performance by patients, but their mean performance on all three sections of the test was less than half as good as that of non-patients. They found it difficult to name from descriptions people whom they could name from photographs. They needed more than twice the time needed by non-patients to complete the test. Within the patient sample the handicap was associated particularly with a diagnosis of schizophrenia, a severe degree of the condition, a long time in hospital, a low I.Q., poor work performance and socially withdrawn behaviour. Each patient appears to acquire a body of knowledge about the names of other people during his first year in a new hospital, but the size of this body of knowledge does not continue to increase after the first year. The data so far available do not show definitely whether this handicap is treatable, or whether current methods of rehabilitation are providing any effective treatment for it.

The personal possessions of 200 chronic psychiatric patients admitted from eleven hospitals in the Birmingham Region to the regional rehabilitation hospital were studied and the number and range of this property is described. The patients had markedly fewer possessions than did inhabitants of other institutions that were studied. Women patients had more than twice as many possessions as men. The eleven hospitals varied widely in the number of their patients' possessions. Possible reasons for this are discussed. The hospital's attitude and the degree of severity of the patient's illness were found to be the most important factors. Length of stay (in the case of men), the intelligence of the patient, and the continuing existence of contact with relatives (in the case of women) were found to be subsidiary factors. Three years after the inventories of their property had been made, male patients with more possessions had responded more successfully to their course of rehabilitation regardless of their clinical condition. Given space, money and a favourable hospital attitude, patients had acquired more property. That it is humane to encourage this is not in doubt, but it is suggested that it may also be therapeutic.

In the history of the Royal Society there have been certain instances of hereditary genius, but there can be few Fellows in whom the influence of both parental strains is seen so clearly as in John Wilkins. He was the son of Walter Wilkins, an Oxford citizen and goldsmith, of whom Aubrey says: ‘Mr Francis Potter knew him very well, and was wont to say was a very ingeniose man, and had a very Mechanicall head. He was much for Trying of Experiments, and his head ran much upon the perpetuall motion .’ (1) ‘He was born in 1614 at Fawsley, near Daventry, in Northamptonshire, in the House of the Reverend and well known Mr John Dodd, who writes upon the Commandments, he being his Grandfather by the Mother’s side. He was taught his Latin and Greek by Edward Sylvester, a noted Grecian, who kept a Private School in the Parish of All Saints in Oxford: His Proficiency was such, that at Thirteen Years of Age he entred a Student in New-Inn, in Easter-Term 1627. He made no long stay there, but was removed to Magdalen Hall, under the Tuition of Mr John Tombes and there he took his Degree in Arts in October 1631.

Of the two components used in Wing's behaviour rating scale it appears that the first, Social Withdrawal, can be used by nurses with a fairly high degree of reliability. The second component, Socially Embarrassing Behaviour, yields rather low inter-rater correlations and in all probability is not readily applicable to the behaviour shown by patients who have been in hospital for many years and are not acutely ill. The assessment of a programme of intensive nursing care, aimed at encouraging personal initiative, social interaction and the reacquisition of elementary social graces shows that such a programme has some effect on patients whose stay in hospital does not exceed thirty years but has no effect on longer stay patients.

IN THE SUMMER OF 1955 Tennessee Williams submitted the movie script for Baby Doll to Elia Kazan, who had been urging the playwright to make a film of two early one-acts: 27 Wag01l8 Full of Cotton (1945), and The Long Stay Cut Short or The U1l8atisfactory Supper (1946). Although the plots of the two short plays are obviously incorporated into Baby Doll, the publisher's note which points out that the script is "quite different from the two short plays," is accurate. The similarities are basically those of plot; the differences, those of setting, of the character of Baby Doll, and of her situation.

Fairtey, G. H. (1959). Proceedings of 7th European Congress of Haematology, London, 1959. Greenwood, R., Smellie, H., Barr, M., and Cunliffe, A. C. (1958). Brit. med. J., 1, 1388. Hoyle, C, Dawson, J., and Mather, G. (1954). Lancet, 2, 164. Long, J. B., and Favour, C. B. (1950). Bull. Johns Hopk. Hosp., ?7, 186. Lovell, R. R. H., Goodman. H. C, Hudson, B., Armitage, P., and Pickering, G. W. (1953). Clin. Sei., 12, 41. Porter, H. (1955). Amer. J. Dis. Child., 90, 617. Pyke, D. A., and Scadding, J. G. (1952). Brit. med. J., 2, 1126. Sulzberger, M. B., Sauer, G. C, Herrmann, F., Baer, R. L., and Milberg, I. L. (1951). /. Invest. Derm., 16, 323. Truelove, L. H. (1957). Brit. med. J., 2, 1135. Wessl?n, T. (1952). Acta tuberc. scand., 26, 36.

We are still retaining long-stay inpatients in significant numbers. They are not all old, they are not readily discharged, and their expectation of life is considerable. Studies from the registers indicate the likely size of the problem, and some details. Other studies (e.g., Mann & Sproule in Wing & Hailey 1972) indicate some possible reasons, and alternative solutions. Different places will vary greatly and results are not easily applied elsewhere. But certainly in Britain, it is not difficult to discover all the newly accumulating long-stay inpatients from one community. The numbers are not too large for each patient and family to be reviewed by a multi-disciplinary team, with the power, and will, to propose alternative care programs, carry them out, and evaluate them. I believe that it is the recently long-stay inpatients who should have priority in the development of alternatives to hospital residence, before their careers are settled for the next 20 or 40 years.

Tokens were swiftly established as conditioned re-inforcers for a large group of long-stay psychiatric patients. The method involved exchanging tokens, immediately they were received, for the back-up reinforcement. This was found to be efficient when compared to a previous study and resulted in considerably greater increases in response rates. The target behaviour was verbal participation in a social activity and the increases in participation were maintained when the exchange of tokens for back-up reinforcement was delayed. The method is especially useful for setting up token programmes.

Chronic alcoholics in the phase of withdrawal after an alcoholic debauche had significantly increased uric acid values in the CSF. The uric acid level in the serum was not raised but the uric acid quotient in the CSF/blood was. These results suggest a selective change in the central nervous system as a manifestation of an increased catabolism of nucleic acids. This may reflect a cellular toxic effect of alcohol on the tissue of the central nervous system known from other organic systems. The uric acid values in the CSF were still increased after a relatively long stay in hospital. Such a continued increased cellular metabolism might explain the development of chronic brain syndrome found in advanced chronic alcoholism.

A retrospective study of a long stay population from 1952-58 shows the patients chosen for tranquillizers in the long stay group are those with the best outlook as far as discharge is concerned. Nevertheless, tranquillized long stay patients when compared with non-tranquillized patients do nothave a better prospect of discharge and may indeed to some extent have a lesser prospect. Hospitaltreatment with tranquillizers does not alter the chance of re-admission of discharged long stay patients. Ward behaviour, apart from some aspects of "disturbance," is little influenced by tranquilizers which are themselves possibly associated with the introduction of new symptoms. Disturbed wards invite treatment and on them, as on other wards, tranquillizers have replaced other sedatives, with the numbers of patients ultimately treated exceeding the numbers previously sedated.

Soon after the installation in Woburn Buildings Yeats brought Arthur Symons on a trip to Ireland. They went first to Sligo, lodging with people called Siberry1 on the slopes of Ben Bulben near the Glencar waterfall. It was Symons’ first visit to Ireland, and he sent an enchanting account to The Savoy of days of soft rain mixed with sunshine on Ben Bulben and of Rosses Point with its “seafaring men who know more of the coasts of Spain and of the Barbadoes than of the other side of their mountains “. Symons was charmed by George Pollexfen, and expressed the opinion that the astrologer might in more favourable circumstances have developed an excellent taste for literature. The fortnight in Sligo was followed by a long stay, diversified by a visit to the Aran islands, at Tulira Castle with Edward Martyn, a new friend met in London through Symons’ friend, George Moore.2 This was Yeats’ first sight of that country of limestone rock, storm-beaten trees and old towers, which lies between Galway Bay and the Clare hills, and is the landscape of so much of his later poetry. George Moore was expected to join Martyn’s house party, and presently arrived.

SynopsisTwo adjacent areas of Greater London are compared to determine their respective use of psychiatric beds of different types. The one-day census is shown accurately to reflect average bed use in any year. The areas and hospitals involved employed different community and social work policies. A difference emerges in the use of long stay beds. A community-based social work service appears to make little impact on the use of short stay beds, and appears less successful than a hospital-related service in preventing hospital chronicity. Community social work services may identify psychogeriatric patients requiring hospital admission.