Since the introduction of chlorpromazine in the early 1950's, various phenothiazine tranquillizers have become established as standard treatment in schizophrenia. However, it is recognized that these drugs have their limitations; every mental hospital contains a large group of schizophrenics whose illness is unaffected or only partially modified by phenothiazines, and some patients develop side-effects sufficiently severe to preclude these drugs being given in fully effective doses.

In previous papers (2, 3) we have set forth our neurophysiopathogenic theory of alcoholism, which is an amplification of Jellinek's hypothesis (1) that the gamma and delta types of alcoholism form an addictive disease. The physical dependence characterized by a state of distress and an overpowering desire to consume more ethanol, assumes three forms: (a) “inability to stop” the ingestion (Jellinek's “loss of control”) noted moments after ingesting a small quantity of ethanol following a period of abstinence, which characterizes the gamma or intermittent clinical form of alcoholism; (b) “inability to abstain” from ethanol hours after the last ingestion and after continuous drinking (each 4 to 8 hours during months or years), which characterizes the delta or inveterate clinical form of alcoholism, and (c) primary physical dependence without ethanol having necessarily been ingested previously, which characterizes remittent, or epsilon alcoholism or dipsomania.

During the treatment of mental illness, a phase is reached when the patient is encouraged to resume his life in the community by spending increasing periods of leave at home.

Wolpe (1958) has described the technique of treating phobias by reciprocal inhibition. The patient is encouraged to relax by appropriate procedures, and is then asked to fantasy a series of situations which he has previously arranged in order of their ability to evoke anxiety. This personal hierarchy of situations is put to him for short periods in ascending order.

There can be no more urgent or conspicuous problem in psychiatry, as a scientific discipline, than that it lacks a generally agreed theoretical framework on which to base practice and teaching.

It is usual to encounter, in any large mental hospital, a group of patients who are considered by the staff to be difficult. This opinion is slowly formed, but, once established and repeatedly expressed in nursing reports and medical records, it rarely alters and may have a powerful influence on the patient's career in hospital. A difficult patient may find himself deprived of privileges and moved to a “lower level” ward (9, 10, 11) and his demotion in this way can affect his relatives' attitudes towards him (17). On the other hand, patients informally classified by the staff as “good patients” may be granted certain advantages and, as Cohen put it, “if they behave okay, they move to a better billet” (5).

Shapiro and Nelson (1955) suggested that an important factor in the cognitive impairment of psychiatric patients was a diminution of present learning ability. They devised a new test in which the subject had to learn and retain the meanings of five previously unknown words. Walton and Black (1957) developed this technique in their Modified Word Learning Test (MWLT). In this test, the patient is given the Terman-Merrill Vocabulary until he is unable to recall the meanings of ten consecutive words. He is then told the meanings of these ten words. If, immediately afterwards, he fails to give the definitions of at least six of them, the meanings of all ten words are given again, changing the wording to avoid rote learning.

It has been shown by Parkes (1) and other workers that about 45 per cent. of out-patient schizophrenics are unreliable at taking their phenothiazine medication. It is in this group that many relapse and require readmission to hospital. Kline (2) quotes that 20 per cent. of in-patients are also unreliable in this regard. With the advent of a long-action phenothiazine injection fluphenazine enanthate, control of these difficult patients may well prove more effective.

Ireland has the highest rate of hospitalized mental illness on record. This is borne out both by the World Health Organization figures for treated mental illness (W.H.O., 1961), by international comparisons of point prevalence rates (Arentsen and Strdmgren, 1959) and by consideration of first admission rates (Hammer and Lcacock, 1961). The Irish national figures for each of these measures were respectively 7·12, 10·81 and 1·45 per 1,000 population in 1959. The rates exhibit a distinct geographical pattern within Ireland: they are highest on the coastal areas furthest from Dublin, while in the Dublin area they are as low as those of most western European countries. All three measures have risen over time, and the intercounty variation has also increased since 1900. In 1959 the coefficients of variation for both first admission and hospitalization rates were equal to 25·1 per cent.

Biochemical studies on the urine of schizophrenic in-patients and out-patients have shown the drug rejection rate to vary from 5 per cent. to 32 per cent. in the U.K., U.S.A., and U.S.S.R. (3, 4, 8, 9, 11, 12). Even higher rejection rates (70 per cent.) were found with depressed out-patients (12), and high rejection rates have been found in antenatal patients prescribed ferrous sulphate, out-patients supposedly taking P.A.S. for their tuberculosis, and patients on drugs for rheumatoid arthritis (1, 2, 5, 6, 7).

The search for objective indices in diagnosis and prognosis of patients suffering from mental illness remains a matter of great clinical interest. While advances in this field have been reported from time to time, no method has become unequivocally established, and in affective disorders much interest has focused on the possible link between mood and physiological change. Cannon's work on the “Bodily Changes in Pain, Hunger, Fear and Rage” (1920) indicated the breadth of this relationship and gave impetus to attempts at rating emotional responses by the severity of their accompanying autonomic changes. Papez (1937) also emphasized that “emotion is such an important function that its mechanism, whatever it be, should be placed on a structural basis”. While this is being sought currently in the limbic system, reticular formation and hypothalamus, the importance of the autonomic system as effector pathway of physiological responses accompanying emotional states has in no way diminished.