Following the work of Dale (1934) and Loewi (1935) on the relationship of choline esterase to the transmission of nervous impulses, a number of studies have been made of the choline esterase activity of the serum in different physiological and pathological conditions. The serum esterase activity varies considerably from one individual to another, but it generally remains very constant in any one individual even over long periods of time; it is believed to be unaffected by changes in diet, exercise, fatigue, or by menstruation. The earlier investigators were unable to correlate the esterase level with any such factor as age, sex, heart rate, blood pressure, weight, or with pathological conditions such as benign or malignant tumours, chronic infections, heart diseases or neurological conditions (v. Verebely, 1936; McGeorge, 1937); they found only a tendency to low esterase activities in acute infections (Hall and Lucas, 1937) and in advanced tuberculosi (Vahlquist, 1935).

In an investigation in which psychopathic patients were included Tod and Jones (1937) and Jones and Stadie (1939) described a number of positive correlations between the serum choline esterase and various clinical conditions. They found a high esterase activity in anxiety states and lowered activity in catatonic stupor, epilepsy, schizophrenia and also in advanced tuberculosis and carcinoma. Antopol et al. (1937, 1938) associated high serum esterase activity with thyrotoxicosis and low activities with liver disease, anaemia and hyperpyrexia. Milhorat (1938), in agreement with Jones and Stadie, attributes the low esterase activities in these conditions to the general debility, but McArdle (1940) concludes that impairment of liver function is the primary cause.

The present work was carried out with the object of obtaining further information as to the relationship between the serum choline esterase activity and anxiety.

The strong association between psychosexual anomalies and mental illness was first brought out by the work of Krafft-Ebing (1902) and Freud (1905). Freud (1911) demonstrated the existence of a latent homosexual element in the structure of the paranoid reaction. He also held the view that, to some extent, every person is psychologically bisexual. A preponderance of instincts concordant with physical attributes of sex, however, would be expected in normally developed adults. The experimental analysis of masculine and feminine traits, carried out by Terman and Miles (1936) with an attitude—interest test, led to conclusions which were in accordance with this viewpoint. Terman and Miles were also able to show that frankly homosexual males and females had mental preferences which corresponded with those of the simulated sex. Thus, from the psychological standpoint, sex is a graded character with a bimodal overlapping distribution. That is to say, although most males and most females have mental attributes which are in agreement with their sexes, many also are mentally intermediate and lie between the two normal modes. Furthermore, some are excessively masculine, some excessively feminine, and a few, who can be said to be “inverted,” possess mental attributes, which belong normally to the other sex. No mental disability has so far been shown to be associated with excessive mental masculinity or femininity, though Terman and Miles found that “supermales” were, on the whole, poorly developed physically. On the other hand, a marked degree of sex inversion is known to be unfavourable to mental stability. Indeed, a significant trend towards sex inversion as measured by the Terman and Miles test has recently been demonstrated by Bosselman and Skorodin (1940) in psychotic patients. A somewhat similar result was obtained by Neal and Penrose (1941), who used a classification test.

The value of electro-encephalography as an aid to the study and diagnosis of nervous diseases is now accepted. The most valuable results have been obtained in cases of organic disease of the brain, particularly in space-occupying lesions and in epilepsy, but considerable attention has also been paid to the changes occurring in cases suffering only from mental disorder. The chief contributors to this subject are listed in the bibliography.

Derivatives of barbituric acid are in general sedatives, hypnotics and analgesics, but sodium amytal (S.A.) occupies a special position, because of its effect on certain mental and nervous conditions. It produces transient amelioration in catatonic schizophrenia and hypnosis-like conditions in neuroses. The latter is important through the fact that one is able to study hypnosis from a different pharmacological point of view.

Hitherto two methods have been commonly used to measure dementia—by means of numerical measures of scatter, and by means of the discrepancy between scores on vocabulary and other tests. In the present investigation the value of the most popular techniques with both methods was examined, and a new short measure of dementia was evolved.

Subjects taking the Stanford Binet and similar tests rarely pass abruptly from complete success at and below a certain M.A. level to complete failure at the next and subsequent levels. For example, a subject with a total M.A. of eleven years may succeed in all the subtests at and below the VIII year level and fail all the subtests above the XIV year level, while between these two levels he succeeds in some and fails others. The range of partial success and failure is called the “scatter.” Many psychometrists believe that unusually wide scatter indicates psychopathy or intellectual deterioration. The various methods for measuring scatter are conveniently summarized by Harris and Shakow (1937).

A long-standing observation on the results of intelligence tests in dementia is that vocabulary ability remains comparatively unimpaired until a late stage when the subject is unable to solve other tests. Therefore, it has been claimed, vocabulary score may be taken as a measure of the subject's pre-morbid intelligence, and the discrepancy between his vocabulary ability and ability on other tests as a reflection of the difference between his former and present intelligence, thus providing a measure of his dementia. The Babcock test is the best known of several techniques, based on this principle, for the measurement of dementia.

While investigating the serum choline esterase activity in anxiety states, a series of successive new admissions to the Neurological Section of the Mill Hill Emergency Hospital were tested with a view to obtaining further information as to the types of cases giving abnormally high or low esterase activities.

Sera giving abnormally high esterase activity were generally found to come from patients who had been diagnosed on admission as anxiety states, but an exception was noted particularly in the case of one patient (P. M—) with the very high esterase activity of 169. This patient was described on admission as “always emotional; he feels like weeping when the National Anthem is sung; not afraid of dangers.” He complained of uncontrollable weeping in company and he had considered suicide. Both from our own observation and from that of others it appeared that he was not a particularly anxious person, but he was extremely depressed. This observation raised the question of whether anxiety is the only emotional condition in which the serum esterase activity is raised or whether it may not also be raised in severe depression.

It appeared that information on this point might be obtained by analysing the data which had accumulated in testing the new admissions, which consisted of a varied collection of patients suffering from anxiety states, depressive states, hysteria and other neurological and mixed conditions. The possibility of subsequent analytical treatment was not considered at the time when the data were collected and the diagnoses were made by more than 12 different physicians who were known to differ to some extent in their diagnostic criteria. For this reason it was hardly expected that the results would be extremely clear-cut, but in actual fact the analysis brought out surprisingly clearly the differences in serum choline esterase activity in different types of neurotics. The diagnoses were made without a previous knowledge of the esterase activities and were therefore unbiased in this respect; we are indebted to the physicians for their permission to make use of them.

Methods.—The method of estimating the serum choline esterase was the same as was described in the preceding paper (Richter and Lee, 1942), except that venous blood from the arm was used instead of capillary blood. In some of the estimations acetylcholine bromide was used instead of the chloride. The bromide ion caused a slight inhibition of the enzyme which was corrected by multiplying by the factor 1·06, which was determined empirically by carrying out estimations on the same sample of serum with the chloride and bromide at the same time. The control group consisted of the 12 normal and 12 surgical patients described in the preceding paper; the mean serum esterase activity for the 24 controls was 75 units. The various esterases occurring in blood have been described by Richter and Croft (1942).

The operation of prefrontal leucotomy presents many aspects; to select one in preference to another would, we feel, do the subject an injustice. We have therefore decided to treat the subject as a whole, and thus avoid limiting the scope of the paper or of any subsequent discussion.

This paper is concerned with a group of cases presenting certain psychiatric symptoms following exposure to the detonation of a nearby high-explosive bomb. These cases show features and present problems which appear from the current literature in this country to have received insufficient attention, or none at all. The cases to be presented are not all of equal significance, but in each there are certain common features which, from the psychiatric angle, have a definite and unmistakable organic stamp, and indicate a relationship, direct or indirect, of the syndromes to structural changes in the brain. These symptoms are characteristic in fact of a slight or moderate degree of cerebral trauma. This relationship is prone to be too easily overlooked. The reasons for this are :

(1) The absence in many cases of a definite history of head injury.

(2) The absence as a rule of at least a long period of unconsciousness.

In consequence, when the patient is seen perhaps some considerable time later this possibility is not considered, and the reaction is dismissed as psychogenic. That this can be done even by trained observers was demonstrated in three of the cases about to be described. All the patients except one were Naval personnel who were exposed to blast in air-raids either ashore or at sea.

Hysterical stupor is rare, and indeed some authorities are sceptical of its existence. There are few references to it in English, either in standard text-books or papers. Oppenheim and Bleuler refer to it in passing, but with little clinical detail. Hoch's benign stupors, in spite of their name, are really psychotic reactions. He refers to invariable intellectual retardation and preoccupation with ideas of death being present, and actually a follow-up has shown that most of these cases were really schizophrenic. Millais Culpin, Hubert, and others writing of war neuroses describe hysterical stupors, but they have been the result of terrifying experiences at the front. The case described below showed features which would appear to justify a diagnosis of hysterical stupor, occurring in an individual subject to little external strain. This, in conjunction with a failure to improve over some weeks, but with rapid recovery after cardiazol treatment would seem to warrant reporting it.

In the normal individual toxic amines produced by bacterial action in the gut or elsewhere are readily destroyed by the amine oxidase, an enzyme which is present in the liver, intestine and other organs (Richter, 1938; Blaschko, Richter and Schlossmann, 1937). This process of detoxication is normally very rapid and efficient, but it has been suggested that in certain pathological conditions the detoxicating system may be defective, giving rise to an abnormally high level of toxic amines in the blood (Quastel, 1937).

The therapeutic procedure of electrically induced convulsions provides a rare opportunity of studying experimental convulsive states in man and their accompanying reflex phenomena, many of which are of great importance in neurological diagnosis. Among the many interesting motor manifestations appearing during the post-convulsive stage is the grasping reflex, which has previously been observed only in certain structural disorders of the brain, usually of the frontal lobes.

That three brothers and their mother should be admitted to a mental hospital on the same day is sufficient cause to be put on record.

The question of invalidism from the Army appears to be inextricably bound up with the rather larger problem of the needs of the Army, with which, therefore, at the risk of seeming obvious, I shall try to deal very shortly.

If one may judge from the opinions of General de Gaulle, adopted largely in the training of Panzer divisions, this war differs from the last in the importance, firstly, of smaller bodies of picked men, and secondly of the continuance of production behind the lines. Thus it would now seem better to train as warriors a smaller number of eminently suitable men, while leaving others to fill those jobs of any essential kind to which they are best fitted.

Partial agenesis of the olfactory apparatus or arhinencephaly is usually associated with other gross manifestations of cerebral malformation. The subject has recently been discussed by Stewart (1939), who described the rare variety in which absence of the olfactory bulbs and tracts constituted the main abnormality. Intermediate between this, the mildest form of arhinencephaly, and the cyclopian brain in which the endbrain fails to divide into hemispheres and cranial nerves other than the first are also affected, comes a transitional group in which a partial separation of the hemispheres has taken place and arhinencephaly is present in varying degree. The present case is an example of this intermediate variety, and owing to the rarity of the condition we have thought it worthy of record, though a lack of reliable clinical and post-mortem information somewhat reduces its value. The brain was found amongst a number at the Hereford County and City Mental Hospital.

In 1897 Ganser (1) gave a lecture entitled “Ueber einen eigenartigen hysterischen Dämmerzustand.” This has been translated literally as on “A specific hysterical twilight state,” which we consider unfortunate, as in keeping the words it loses the sense of the original, for the notion of a twilight state remains foreign to us, and is better rendered as a “dimming of consciousness” or “clouding of consciousness.” Further, the concept of hysteria has changed considerably since then and his cases would now be regarded as psychotic.

Drs. Stern and Whiles, in an interesting and provocative article in the January issue (1), claim to have solved the problem of Hamlet on the assumption that Hamlet suffered from the Ganser state occurring during the course of another psychosis. By this theory they hope to reconcile the seemingly contradictory views that Hamlet was insane, and that he was pretending to be so. He was both, they say, and the latter because of his being in the Ganser state.

The authors claim to have examined the problem from a strictly psychiatric viewpoint; but it must be remembered that such a viewpoint is necessarily subject to many limitations, inasmuch as there exists no parallel to Hamlet in actuality. One has constantly to bear in mind that Hamlet is not an historical personage, but a character in a play, and that our task is not to explain some Hamlet of our own, but Shakespeare's Hamlet; and in consequence our theories must not only be psychologically acceptable, but must conform with the text of the play which, after all, is the final arbiter. With this in mind, a psychiatric study of Hamlet may be of great value, but it need not and perhaps cannot be expected to “explain” Hamlet.

The demonstration by Zondek (1936), subsequently confirmed by Cramer and Horning (1936), Gardner (1937), Collip (1936), Noble (1938), Deanesley (1938, 1939), Pybus and Miller (1938), that large doses of oestrone will impair and partly suppress the functions of the pituitary anterior lobe, especially the gonadotrophic and the growth hormone production and will produce partial degeneration of the acidophil cells, led Kirklin and Wilder (1936) to adopt this method of treatment for patients suffering from acromegaly. Their series consisted of eight patients, four men and four women, and their results may be briefly summarized as follows: There was a general improvement in three patients; headache which was originally present in six cases disappeared in four, but returned in one case, though this may have been due to a discontinuance of treatment; in three patients there was a decrease in size, in one a smaller hat was required and her dental plate became loose, in one the hands became smaller, and in one shoes became looser; the visual fields were originally altered only in three of the eight patients, and in one of these the fields returned to normal, in one there was no change, and in the third a progressive hemianopia accompanied by erosion of the sella turcica developed during treatment; hyperidrosis and intolerance of heat, originally present in two, disappeared in both; finally there was loss of libido in three cases.