It is generally accepted that situations of danger, stress or emergency lead to an increased activity of the sympathetic system and to the discharge of adrenaline from the adrenal medulla. Until recently our knowledge was based, essentially, upon two lines of evidence; on the observation of effector organs and mechanisms, such as heart rate, blood pressure, width of skin capillaries, etc., and on the measurement of the adrenaline concentration in the suprarenals or the suprarenal veins, which contain comparatively large quantities. Lately, with the advent of more refined techniques, further methods have become available, which made it possible to estimate adrenaline in tissues other than the suprarenals, in urine and in peripheral blood. The last two methods are obviously of special importance for clinical studies.

In this paper work done in the writer's laboratory will be briefly reviewed. The first part deals with the development of a method for the estimation of adrenaline and noradrenaline in plasma and with experiments that were intended to establish the validity of the method. The concentration of adrenaline and noradrenaline, and the form of their occurrence, in plasma and CSF, will be discussed. In the second part results will be described, which suggest that there is a correlation of the blood-adrenaline level with mental activity.

Cortical undercutting, as an alternative to standard leucotomy and to the major operation of topectomy, was devised by three surgeons independently. Scoville (1949) published his preliminary results soon after McKissock had begun to do rostral leucotomies. Both have continued to use this type of operation (Scoville et al., 1951; Scoville, 1954) but Ferey (1950), the third to develop a similar technique, was disappointed with the results and soon abandoned it (Ferey, 1953). McKissock (1951) reported the initial impressions of the results in 100 cases and by the end of 1952 had operated on 240 cases. During 1953–54, 1½ to 5 years after operation, I followed up these patients, visiting 175 of them in their homes, and 35 in hospital. Personal follow up was refused or for some reason impracticable in 17 cases, including 4 whose case notes had been destroyed; 13 others had died before the survey was made.

Partridge (1950) reported a follow up study of 300 cases operated on by the same surgeon by his “standard” technique (McKissock, 1943); he had the advantage, which I had not, of being able to see his patients before operation. I have had to work retrospectively, and the case notes available, whilst often excellent, had usually not been made with the idea that they would be needed for follow-up purposes. I have not, therefore, thought it right to draw more than broad conclusions from this study.

“Standard” leucotomy in the plane of the coronal suture is undoubtedly an effective treatment for many cases of otherwise hopeless prognosis. The main objection to its use, resulting in many “modified” operations being devised, has been the occurrence of serious personality deficits afterwards. Ström-Olsen and Tow (1949) found that these handicapped nearly three-quarters of patients with “severe neurotic depression, obsessive-compulsive neurosis and chronic tense hypochondriasis”, and though 76 per cent. were relieved of illness only 8 per cent. were in full employment. Tow (1952) has repeated his concern at the serious damage inflicted on well-preserved personalities. Partridge (1950), who has given a full account of the personality changes after McKissock's (1943) “standard” leucotomy, detected some personality deficit in nearly every case of the 300 he investigated and suspected that intellectual impairment was present in all, though he could only be sure of it in a proportion. I have elsewhere (Pippard, 1955) reported the clinical results in 240 cases followed up 1½ to 5 years after rostral leucotomy by Mr. McKissock and this paper should be consulted for details of the operative techniques and scales used for rating the results.

Bilateral blind rostral leucotomy has been shown to be an adequate operation for the relief of many tense psychoneurotic and depressive states (McKissock, 1951; Pippard, 1955); the operation gave worthwhile results in about two-thirds of such cases in a series which included many who were unsuitable. This paper is concerned with the results in 27 cases operated on more than once.

Four patients had already had standard leucotomies with inadequate relief of symptoms; an open rostral leucotomy in one of these, a young ruminative schizophrenic, made no obvious difference. Another schizophrenic had a rostral G leucotomy to divide fibres in the inferior medial quadrant which might have been missed by the earlier standard operation (Sargant, 1953). Afterwards she no longer needed maintenance E.C.T. to keep her at a good level; reduction in tension which followed this limited incision, and the greater ease with which she could be cared for in hospital certainly suggests that a limited operation on the medial side may well be considered in some cases in which standard leucotomy has failed, and certainly before undertaking anything as drastic as Freeman and Watts' (1950) radical operation.

Another patient similarly submitted to a rostral G leucotomy had slowly relapsed after an initially successful standard leucotomy for a chronic tension state. He had, however, been left with a marked intellectual deficit and troublesome urgency of micturition and, if anything, his deficits were increased after the second leucotomy, without any useful relief of symptoms.

We all know cases who have got better and we like to think that we played a part in causing their improvement. To prove this is, however, a very different matter. We have all read the follow-up studies based on a carefully selected group of cases where the authors report on those whom they could trace—but what of the untraced? At times, an overall survey of one's case material may reveal facts unnoticed in the preoccupation with the day to day clinical work.

Parnell (1951) reported that 76 men undergraduates at Oxford had lost a full term's residence on account of psychological ill health in the period of three years from 1 January, 1947 to 31 December, 1949. Psychological ill health had caused 52·5 per cent. of all prolonged absence through illness, a fact which emphasized the need for more detailed study of the causes and possibility of prevention of psychological disturbance. As an indication of minimal current prevalence of such disturbance, it may be reported that 59 Oxford students in need of psychiatric help were referred by their general practitioners to the Warneford and Park Hospitals in twelve months from 1 April, 1953 to 31 March, 1954: these figures take no account of the numbers treated elsewhere; but the evidence as a whole shows that, as found in 1951, mental upset is still the most important cause of ill health in Oxford students.

Information derived from a comparison of somatotype, electroencephalographic, psychological and psychiatric findings upon patients and healthy controls is summarized in this paper. It shows that, despite a probable bias in the controls, significant differences can be detected between the two samples. Some of these differences were sufficiently marked to form the basis for a simple heuristic method of detecting vulnerability.

The following facts concerning West African witchcraft were observed and recorded by the present writer while working as an ethnologist in the Gold Coast. The writer had not, at that time, any psychiatric experience, but has since worked in British mental hospitals long enough for the facts to invest themselves with psychiatric significance.

Chlorpromazine hydrochloride (Largactil) introduced by Laborit (1952) has aroused considerable interest on account of its varied pharmacodynamic actions and clinical reports drawing attention to its possible use in anaesthesia, general medicine and psychiatry.

Chemically related to certain antihistamine drugs, it has little antihistaminic activity itself but has diverse effects on the nervous system. It is a neural depressant with central and peripheral action, vagolytic and sympatholytic properties. (Chauchard, 1952; Courvoisier, 1953; Sigwald and Boutier, 1953; Staehelin and Kielholz, 1953; Lehrman and Hanrahan, 1954; Anton-Stephens, 1954; Winkelman, 1954; Garmany, 1954; and Elkes and Elkes, 1954.)

Enthusiastic claims have been made regarding the therapeutic value of chlorpromazine in a wide variety of psychiatric disorders; many of these have failed to carry conviction, as most of the reports are based on mixed groups with an insufficient number of patients in each diagnostic category to justify definite conclusions and also because controlled procedures were rarely used.

We therefore decided to confine our investigation to one type of psychiatric disorder and chose anxiety states, since the reported pharmacodynamic actions of the drug suggested that it might be of value in the treatment of states of anxiety and tension. The total group studied consists of 150 patients all of whom are treated as out-patients.

The recognition of a well-established psychosis due to arteriosclerotic or senile brain changes rarely presents any difficulty. However, increasing numbers of elderly people are seen with affective, paranoid, or neurotic manifestations, and it is sometimes very difficult to decide whether their symptoms present prodromata of an organic psychosis, or whether in the absence of degenerative brain disease they are occasioned by a variety of endogenous and environmental causes leading to a “functional” psychiatric illness.

In determining the diagnostic value of psychological tests the usual external criterion is the psychiatric diagnosis. This criterion has suffered a steady decline in prestige among both psychiatrists and psychologists. The following remarks by Noyes (1953) would be endorsed by many psychiatrists: “The principal value of classification is not in the categorizing of a disease entity but in quickly eliminating those considerations which will be least useful in understanding the patient and in directing attention to those which are likely to be relevant. Except in organic disorders a classificatory diagnosis is less important than a psychodynamic study of the personality. The psychiatrist should be interested in processes, not in labels … we should endeavour not so much to fit the symptoms into a classificatory scheme as to understand the sick person in terms of his life experience.”

Owing to the increase in the expectancy of life, there is an increase in the incidence of aged people suffering from mental illness who are admitted to hospital. This has stimulated the paying of special attention to the problems of differential diagnosis in order to avoid lengthy hospitalization wherever possible. Recent studies have tended to emphasize the frequency of affective disorders as well as senile dementia in aged patients. It is consequently important to distinguish the former group because of the greater possibilities of treatment there than in senile dementia. A recent paper (O'Connell, 1954) has been concerned with the study of case material of patients over the age of sixty admitted to this hospital. The present study is largely based on material obtained from patients drawn from O'Connell's sample, but also includes cases with longer hospitalization.

In spite of more than twenty years experience with insulin coma therapy psychiatric opinion as to its efficacy is by no means unanimous. While some recent large scale studies (Polonio and Slater, 1954; Paster and Holtzman, 1949; Barres, Ey and Laboucarie, 1953) point to a significant rise over the spontaneous recovery rate with the use of insulin, others (Jensen, 1952) do not find more than an acceleration of recovery already in process. Inasmuch as most investigators acknowledge an increased number of relapses in treated patients this latter view has some support. However the strongest case for insulin is that, if nothing else, it greatly reduces the patient's stay in hospital (Sargant and Slater, 1948; Hughes, 1951). If one remembers, however, the extra administrative and medical staff required to run an insulin ward this point is largely negated. In fact there are some (Bourne, 1953; Notkin et al., 1939) who would claim that any improvement shown in insulin treated patients arises from the extra care and individual attention given them.

Pellagra is a rare disease in Great Britain. The majority of cases occur among patients in mental hospitals and institutions (Stannus and Gibbons, 1934), and more recently it has been described as an accompaniment or complication of a chronic psychosis (Hardwick, 1946). Sporadic cases do arise in the general population (Davis and Hinden, 1941), but it is likely that in many instances the disease goes unrecognized (Deeny, 1942). Pellagra is particularly uncommon in British children (Greenfield and Holmes, 1939), although observers in areas where the disease is rife are of the opinion that it is found more frequently in children than in adults (Weston and Weston, 1948).

Mental symptoms are frequent in pellagra and may, in fact, precede the other manifestations (Sydenstricker, 1943). Severe psychoses occur in untreated cases and depressive, manic and paranoid reactions have been described (Hardwick, 1946). In children, however, symptoms are usually mild and mania or delirium is not often present (Holt and Mcintosh, 1953); therefore this case of pellagra with a psychotic reaction in a 10-year-old English schoolboy may be of interest.

Pellagra with marked mental symptoms in a boy of 10, was cured by nicotinamide (Hersov, 1955). The boy's diet prior to development of the pellagra did not however appear to have been deficient in nicotinic acid derivatives. The following studies were initiated in search for a metabolic peculiarity which might explain this.

Altered adrenocortical activity has been reported in patients suffering from primarily psychiatric disorders by Hemphill and Reiss (1947), Reiss, Hemphill, Gordon and Cook (1949a and b) and others. The chance finding of a high urinary copper-reducing steroid (CRS) excretion in a man suffering from recurrent depressive illnesses who was suspected of having Addison's Disease, prompted us to investigate the excretion of these steroids in a group of un-selected psychiatric patients. We report here the results of 23 estimations on 21 patients.

That variations of blood-pressure are found in states of emotion is commonplace knowledge; that rises may take place with temporary fear and anxiety is also well known, but that anxiety occurs with a reduced or normal blood-pressure is not perhaps so well appreciated.

The purpose of the present investigation was to determine whether the blood-pressure remains high when the patient with anxiety is in a state of overt placidity and calmness.