Earlier investigations (3, 4) have shown an abnormal glutamic acid metabolism in schizophrenic patients.

These changes are, briefly, low glutamic acid level (and high glutamine level) especially in acute cases. Glutamic acid concentrations below 1.2 milli grams per 100 ml. venous blood were ascertained in most of these patients.

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 this paper, the term Acute Infantile Cerebral Diplegia has been used to denote a group of cases in which a spastic paralysis, affecting principally the lower limbs, develops suddenly in infancy or childhood. The course of the disease is remarkably uniform in the majority of cases, thereby suggesting a common pathogenesis.

Because of their rapidity of onset, brevity of action and relative safety, the choline succinic ester derivatives, in the last two years, have almost completely superseded tubocurarine, gallamine and decamethonium as muscle relaxants in electroplexy. The literature now contains a number of reports of prolonged respiratory arrest associated with the use of these new relaxants. In publishing the results of early experience at Long Grove with three of the new compounds, Monro et al. (1953), tended to favour Scoline with thiopentone in a body-weight dosage using a one-syringe technique. The infrequent occurrence of excessive apnoea proved to be no great problem and was easily dealt with. However, during subsequent work in the same hospital, we were impressed by the markedly more abrupt action of suxethonium (Brevidil “E”) and felt that further investigations into its clinical properties might yield some reward.

The use of chemically induced convulsive therapy introduced by Von Meduna in 1934 was followed by the introduction of electric convulsive therapy by Cerletti and Bini in 1937. The latter method is now of almost universal use. The main reasons for the change over were the elimination of the unpleasant aura experienced in connection with the leptazol fit and the fact that body accidents were said to be less frequent with E.C.T. There does not appear to be any evidence of greater therapeutic efficiency with E.C.T. Bini and Bazzi (1949) in summarizing statistics covering twelve thousand cases, found no difference in the remission rates in the two therapies. Dedichen (1946) indicated that the value of the two therapies in depressions was similar and Ross (1946) found this also for cases of acute excitements.

It is natural to assume that because a psychosis occurs during the process of childbearing the two events are therefore necessarily associated, but the evidence is conflicting and the relationship between them has not been established with certainty. In fact no immediate dramatic cause has yet been demonstrated that would account for such mental breakdowns, and it would be surprising if it had, for the great majority of psychoses not related to maternity show no simple sequence of cause and effect.

Yet it would be wrong to dismiss without further examination an occasion so important in the life of the mother as childbirth as of no aetiological consequence. In the types of psychosis under consideration the clinical onset had often been a sudden and disturbing event, just at that particular time in the patient's life when she was confronted with the responsibility of motherhood. Further examination of the patient's history however often revealed previous evidence of emotional disturbance, or of instability in other members of her family.

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.

Introduction Since the publication of Rorschach's Form Interpretation Test in 1921, its applications have been extended to cover an increasing number of clinico-psychological problems. Of these, one of the most important and difficult is the diagnosis of organic brain damage and pathology.

Chlorpromazine hydrochloride (3-chloro-10 (3′-dimethylamino-propyl)-phenothiazine) or “largactil” is being widely tried out as a form of therapy in psychiatric disorders. Papers have appeared describing its use in comparatively severe conditions encountered in in-patient mental hospital practice (e.g. Anton-Stephens, 1954) and in psychoneurotics (e.g. Garmany, May and Folkson, 1954). In the psychoneurotic group in particular, the drug is reported to be helpful in reducing tension and diminishing pre-occupation with worries, fears, and concomitant symptoms. These two properties—the reduction of tension and the production of a feeling of relative indifference to distressing stimuli—were amongst those originally attributed to chlorpromazine by Sigwald and Bouttier (1953) and, of course, they approximate to the characteristic changes resulting from prefrontal leucotomy (Partridge, 1950). The effects of this operative procedure have been extensively studied in relationship to such factors as the previous personality of the patient and the duration of the illness involved (e.g. Baker and Minski, 1951) and it was considered that it might be of value to investigate similar factors in patients treated with chlorpromazine. It is true that prefrontal leucotomy entails structural damage as a result of which the previous personality, for example, may be expected to have a significant bearing on the therapeutic outcome, but even with patients treated by chlorpromazine the ultimate result may depend, at least to some extent, on the inherent make-up of the individual or the symptom-complex from which he is suffering. It was in order to study the relationship between factors of this nature and chlorpromazine treatment that the following investigation was undertaken.

It is generally assumed that an activation of the sympathetic system plays an important part in the therapeutic efficacy of convulsive treatments, be it as an unspecific result of stress or owing to a more circumscribed stimulation of specific centres in the hypothalamus and elsewhere. Such an effect has been postulated on the basis of various changes observed after convulsions, such as a rise in blood pressure (Accornero, 1940; Bini and Puddu, 1940; Piette, 1950), hyperglycaemia (Castelluci, 1940; Kessler and Gellhorn, 1941), leucocytosis and lymphocytosis (Gellhorn and Frank, 1948, 1949; Michael, 1949) and eosinopenia (Altschule, Parkhurst and Tillotson, 1949). Pupillary dilatation and contraction of the nictitating membrane have been described in cats (Gellhorn and Darrow, 1939). More direct evidence is provided by the finding that the adrenaline stores of the adrenal medulla are decreased after electrically produced convulsions (Pekkarinen, Hakala and Hyppönen, 1952).

It is established that healthy individuals and schizophrenics respond in different ways if subjected to stressors (“alarming stimuli”) under seemingly identical conditions. It is also common knowledge that healthy individuals react differently under the impact of “alarming stimuli” than individuals already under stress, i.e. for instance, suffering from certain psychosomatic manifestations.

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.

The chemical compound 3-ortho-toloxy-1,2-propanediol, known as mephenesin, Myanesin or Tolserol, was shown by Berger and Bradley in 1946 to depress reflex excitability of the spinal cord and to have a depressant action at higher levels of the central nervous system in higher dosage. Other investigators confirmed this and the drug has been found effective for the spasticity and tremor of some neurological conditions.

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.

Maladjustment at work is not synonymous with sickness, but when a middle-aged man becomes grossly inefficient in a job at which he has previously excelled, the chances are that he is ill. This paper describes such a case, and the investigations that led to the diagnosis by cortical biopsy of Alzheimer's Disease. So far as is known, this is the first recorded instance in this country of Alzheimer's Disease being diagnosed histologically during life. Apart from its interest as a clinical curiosity, however, this case illustrates some practical problems often arising in the assessment of this type of patient, which can be as difficult and responsible a task as any that the psychiatrist has to undertake.

In connection with a demonstration programme of comprehensive psychiatric care for hospitalized schizophrenic patients, it was necessary to develop a rapid and effective method for rating patients' ward adjustment and social behaviour. The scale, entitled the Albany Behavioural Rating Scale (ABRS), and its validation, are described in this report. The nature of the problem required that the scale be readable, easily completed and scored, and suitable for use by nursing and rehabilitation personnel (OT, CT, Music Therapist, etc.). Further requirements included adequate scoring reliability and validity, as well as amenability to quantification.

Various rating scales have been described in the psychiatric literature, but these did not meet our needs. Some were too cumbersome and time-consuming. Others required individual psychiatric interview. Frequently they demanded high literacy of the rater. Certain scales are indeed useful for special purposes, as for example the MSRPP (Lorr, 1953) which can be employed with confidence as an aid to psychiatric classification. Lucero and Meyer (1951) have discussed the requirements of an adequate rating scale.

Mephenesin is a muscle relaxant which acts mainly on the spinal cord but which also has a definite effect on the thalamus, the basal ganglia and the brain stem. It relaxes hypertonic muscles, without appreciably reducing motor power, and allays fear and tension.

In 1946 Berger and Bradley showed that mephenesin caused muscular relaxation and, in the same year, Stephen and Chandy (1947) reported that the intravenous administration of mephenesin to human subjects was usually accompanied by a feeling of euphoria and relaxation. The clinical trial of mephenesin in neurotic states associated with tension and anxiety was a natural corollary of these findings. Reports of its efficacy have been conflicting, but this is hardly surprising when a new drug is introduced for the treatment of a common disorder whose natural course may be either chronic or self-limiting, which is subject in a marked degree to apparently spontaneous fluctuations in intensity and on which the effects of suggestion are notorious. The assessment of therapy is made more difficult by the fact that there is no satisfactory objective method of measuring changes in the degree of anxiety; the investigator must either use tests the relevance of which many people will dispute or he must rely on clinical assessment, a subjective judgment very dependent on the skill and experience of the clinician. As Bradford Hill (1951) has stressed, clinical assessment can only be given full weight in a therapeutic trial when the possibility of enthusiasm or scepticism on the part of the clinician is eliminated. Such elimination of bias is best achieved by treating one group of patients with the drug and another group with a placebo, the clinician, nursing staff and patients not knowing to which group any particular patient has been assigned.

Sodium amytal has long been regarded as a physiologically inhibiting drug. It is widely used in clinical practice as a sedative and sleep-producing drug, although all of its precise pharmacological effects are not definitely established. It has also been suggested that sodium amytal produces an increase in extra-version, as manifest by an increase in communicativeness, etc. Thus Lindemann (1932) found that after receiving amytal, normal subjects report feeling of increased well-being, co-operativeness, serenity and friendship. Sodium amytal is also used for the reduction of manifest anxiety. Sargant and Slater (1954) cite many examples of its use for this purpose with neurotic subjects; they describe it as useful for “deconditioning to situations likely to produce anxiety”. Masserman (1938) reports that amytal apparently reduces the sympathetic activity in cats which normally results from faradic stimulation from the hypothalamus. It has also been shown to abolish conditioned fear responses in kittens (Bailey and Miller, 1952).

The literature related to conditioning is enormous. Hilgard and Marquis (1940) alone have a 973 item reference list at the end of their book. It has been established that anxiety neurotics or anxious subjects condition better than normals (e.g. Welch and Kubis, 1947a, 1947b; Taylor, 1951; Spence and Taylor, 1953; Spence and Farber, 1953). In the terminology of Eysenck (1952, 1953), in which introversion–extraversion and neuroticism are two orthogonal dimensions, anxiety neurotics are part of the groups known as Dysthymics, i.e. they have high scores on both the introversion end of the introversion–extraversion dimension and on the dimension of neuroticism. On the other hand hysterics and psychopaths have been shown to have high scores on the extraversion end of the introversion–extraversion dimension and on the dimension of neuroticism. Figure 1 will make this clear.

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.