Most people feel that they understand the word ‘morale’, though few may have attempted to think precisely about it. Certainly all great leaders throughout time have understood it in varying degrees, often purely instinctively. ‘Morale is at bottom a state of will or purpose’ was the way Hocking (1918) wrote of it in his book Morale and its Enemies, and over two hundred years ago Marshal Saxe in the same vein remarked ‘The secret of victory lies in the heart of human beings'.

The literature on the role of the wife of the alcoholic in his illness and its management has been critically reviewed by Bailey (1961). She points out that research findings are contradictory and that a unitary view of the wife's role is unwarranted. Kogan and Jackson (1964) have demonstrated within-group differences among alcoholics' wives with regard to their perception of their husbands' illness, and have suggested that such differences may have important prognostic implications. Rae and Forbes (1966) have offered a psychometric dichotomy based on the M.M.P.I. which appeared to distinguish a group of wives whose attitudes to their husbands' illness were supportive and realistic, in contrast to a group whose attitudes appeared to be the reverse. These latter wives were characterized by the M.M.P.I. as having the Psychopathic Deviate scale as a prominent feature of their personality profile. There have been no follow-up studies to assess the influence of the wife on her husband's response to treatment, and the present research attempts to assess this and to relate clinical variables to the psychometric characteristics of the marital partners.

In a previous study (Drewery and Rae, 1969), using the Interpersonal Perception Technique (I.P.T.) (Drewery, 1969), it was found that while the husbands and wives of the non-patient marriages had a clear concept of masculinity which they shared, the partners in the alcoholic marriages lacked this consensus; they were confused about the male socio-sexual role, and this confusion expressed itself in a conflictful interplay of dependence and independence needs. The conclusions then reported were applied to alcoholic marriages as if they formed a homogeneous group. The present study was designed to test the hypothesis that when alcoholic marriages are dichotomized in terms of the wives' Pd characteristics, two qualitatively and quantitatively distinct marital patterns would be revealed.

A woman was admitted to a psychiatric hospital. Feeling increasingly depressed she had made a suicidal attempt. Besides somatic complaints, she related friction with her husband. The latter reported her as being inadequate at coping with their children, with general domestic chores or with entertaining his business friends. The woman's full scale I.Q. on the Wechsler Adult Intelligence Scale was found to be 73, in the borderline subnormal range.

Few papers have been published on psychiatric disorders presenting in casualty departments. Such a study was last reported at Guy's Hospital in 1960 by Blackwell and Mallett. The present report deals with those psychiatric cases who attended the same casualty department during a recent period of twelve months.

There have been a number of reports of psychiatric referrals in general hospitals. The most recent papers have been by Guy Edwards and Angus (1968) from Bergen Pines County Hospital, New Jersey; Crisp (1968) from the Middlesex Hospital, London; Bridges et al. (1966) from King's College Hospital, London; and MacLeod and Walton (1969) at the Western General Hospital, Edinburgh. The last report from Guy's Hospital, London, was over a five-year period from 1955–60 by Fleminger and Mallett (1962). It was therefore thought useful to review psychiatric referrals from the general wards at Guy's over a recent period of one year, approximately ten years after the first study, to see if there had been any change in the pattern or nature of the referrals.

During the past two decades the psychosocial environments of psychiatric wards have become of increasing concern. Different investigators have described the importance of the therapeutic milieu of such wards and have implied that treatment environment strongly influences treatment outcome. At first there were detailed observations and naturalistic descriptions indicating the importance of ward social structure in facilitating or hindering treatment goals (Stanton and Schwartz, 1954; Caudill, 1958). Then came a variety of different types of ward programmes designed to use the ward environment as an important treatment modality (Jones, 1953; Cumming and Cumming, 1962; Fairweather, 1962). These different approaches present quite different specific recommendations about the most effective types of treatment environments; however, they do all agree on one essential point: that the immediate psychosocial environment in which patients function is an important determinant of the outcome of the treatment process.

A survey has already been presented (British Journal of Psychiatry, November 1971) of all patients seen by the senior psychiatric staff of Leverndale Hospital and the Victoria Infirmary, Glasgow, with a view to termination of pregnancy for the period of two years following the implementation of the Abortion Act, i.e. from April 1968 to April 1970. During this time 116 patients were seen, of whom 71·5 per cent were recommended for termination. Follow-up of cases not so recommended showed that one-third obtained abortion elsewhere; the rest apparently made a reasonable adjustment to their situation.

Psychiatric Social Work as a profession with its tradition, training and culture rooted in the Hospital Service, will in all probability soon cease to exist. It would appear that the imminent decease of this profession is not generally known or understood. This account, an expression of much personal regret, is also an attempt to give a background to the current situation. It pays tribute to the medical profession, without whom the Psychiatric Social Workers would never have acquired their specialization and expertise. It has been in hospitals and other allied settings that the Psychiatric Social Workers have practised their professional skills and had the opportunities to keep abreast of clinical progress and new approaches to mental health, so essential to teaching new generations.

The renewed use of modified forms of narcosis, generally given together with ECT and antidepressant drugs, arose from a series of observations made during attempts to treat a group of chronically tense patients. These patients, the majority of whom had been diagnosed as ‘chronic tension states', had been referred to the Department of Psychological Medicine at St. Thomas' Hospital for assessment regarding their suitability for modified leucotomy. Birley (1964), in a follow-up study of previous patients with ‘tension states' treated by leucotomy at St. Thomas' Hospital, had found that many developed clear-cut attacks of depression following the operation. This suggested to one of us (W.S.) that such ‘tension states' might have been masked depressive illnesses, in whom the underlying diagnosis had been missed. Consequently it was decided that in the future such patients should be treated with suitably long courses of ECT, together with one or both groups of antidepressant drugs, before any question of recommending leucotomy arose. As a result, a considerable number of these patients were greatly improved and no longer required a leucotomy. Others, however, became more tense and distressed during treatment with ECT and drugs; modified narcosis, therefore, was given in addition, to allow the full course of ECT to be completed. It was then that another of us (C.W.) observed that patients who were treated with combined narcosis, ECT and antidepressants appeared to respond more favourably, and were much less upset by the treatment, than those receiving ECT and antidepressants alone. In a preliminary report published in 1966, Sargant, Walter and Wright described a group of 73 patients with ‘chronic tension states', of whom 67 per cent had improved markedly with further treatment of their underlying depression. It was noted that 15 of the 37 patients treated with ECT and antidepressants alone still required a leucotomy, while in the group treated with modified narcosis in addition to ECT and antidepressants the operation was needed in only 3 of the 36 patients. It appeared, therefore, that the addition of narcosis to drugs and ECT greatly improved the recovery rate.

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.

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.

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 Eysenck Personality Inventory (E.P.I.) was developed by Eysenck and Eysenck (1964) to measure two dimensions of personality—extraversion (E) and neuroticism (N). This personality questionnaire has been extensively used in clinical practice and psychosomatic research. In our own department we have been using the E.P.I. as a tool in some psychosomatic investigations, which have been reported in various journals (Verghese, 1970, 1971; Verghese et al. (1971a), (1971b).

There have been reports of the association of alterations in the divalent cation content of plasma with depressive illness. Coirault and colleagues (1959) found increased ionized calcium levels despite decreased total plasma calcium concentration in patients recovered from depression. More recently, Frizel and colleagues (1969) have reported normal plasma ionized and total calcium levels both before and after recovery from depression.

In 1969 Barton and Whitehead reported two cases in which there were definite plots to remove an unwanted and restricting relative by securing admission to a mental hospital, and one case of an old lady admitted to a mental hospital following induced faecal incontinence. The old lady was considered a nursing home nuisance and she was given purgatives regularly. Inevitably she had some ‘accidents' and these were used as an excuse for removing her to hospital. They labelled such attempts ‘The Gaslight Phenomenon’, inspired by Patrick Hamilton's play Gaslight which was first produced in London in 1939 and later formed the basis for a film.∗ Their survey of the literature uncovered few recent reports of such manipulations.