There exists a vast literature on the puerperal psychoses. Most of it is incomplete in that rarely is any definition of the “puerperal period” made; frequently there is no attempt to differentiate between the various clinical syndromes seen when aetiology is considered, and little consideration is given to the extent of constitutional predisposition to psychiatric illness in the probands.

Neurosyphilis, causing a psychotic illness of such severity as to necessitate admission to a mental hospital, though now rare, has not been completely eradicated. This study is based on 91 psychotic patients with neurosyphilis admitted to six mental hospitals between 1950 and 1965. Its main purpose is to ascertain the incidence, and to present the natural history of the neurosyphilitic psychoses during a period when antibiotics were available. It is likely that some patients in this series were given penicillin for an intercurrent infection in complete ignorance of the underlying syphilitic process. Indeed, Joffe, Black and Floyd (1968) and Heathfield (1968) have reported modifications in the clinical picture of neurosyphilis, tending to mask the diagnosis, caused by earlier administration of antibiotics for intercurrent infections. Thus the widespread use of antibiotics, though greatly reducing the incidence of neurosyphilitic psychosis, may well have increased the mutability of the disease as reflected in its changing prevalence, distribution and clinical characteristics.

As Mr. Justice Marshall said recently when making the appropriate hospital order: “The interests of the public are best served by curing the patient”, but with psychopathic disorder some still believe cure to be virtually impossible (Cleckley, 1953; Gould, 1959) and others doubt whether the condition can be treated at all. Genetic endowment (Heaton-Ward, 1963), damage to the developing foetus (Stott, 1962) and early adverse childhood experiences (Scott, 1963) have been thought to militate against later treatment success. Unfortunately all writers in this field are handicapped by the lack of long-term follow-up studies on the natural history of the condition.

The “punch-drunk” syndrome of boxers was recognized by lay people many years before it received attention from the medical profession. The syndrome included slurred speech, ataxic gait and impaired mental function and so simulated alcoholic intoxication. Martland (1928) gave the first clinical description of its neurological and psychiatric features. These consisted of cerebellar, striatal and pyramidal signs in varying combination together with dementia and sometimes episodic psychotic behaviour. Martland stressed the psychiatric features of the syndrome, and noted that of 23 punch drunk boxers known to him, four were permanently in mental hospitals.

Studies on the biological basis of psychosis are currently being conducted in a variety of disciplines and using a wide range of techniques (Smythies, 1968). These include studies of the basic mechanism of action of drugs which mimic, exacerbate or ameliorate psychosis. A major sub-section of the field is composed of structure-activity relationship (S.A.R.) studies in which we determine what effect the systematic manipulation of the molecular structure has on the activity of a drug. In this way valuable data can be obtained as to its possible mode of action. This in turn may suggest hypotheses as to the biochemical lesions in the naturally occurring psychoses. Secondly, specific behavioural responses can be made the dependent variable we measure in experiments where the levels of brain amines, activity of brain enzymes, etc., can be manipulated by any of the many techniques now available.

One of the hypotheses advanced to explain the processes underlying severe depression postulates a change in brain function due to an alteration in the distribution of cations across the neuronal membranes (Shaw and Coppen, 1966; Shaw, 1966). Electrophysiological evidence of abnormal function of pathways in the nervous system in depression has been obtained by the study of evoked cortical potentials (Shagass and Schwartz, 1966), but evidence of derangement in the distribution of cations between the cells and extracellular space has come only from “whole body” studies (Coppen and Shaw, 1963; Coppen, Shaw, Malleson and Costain, 1966; Shaw and Coppen, 1966).

In 1951, J. Cammermeyer and R. Gjessing (I) reported one case of fatal myocardial fat embolism in periodic catatonia with fatty liver. This patient had suffered from periodic catatonia for many years and had been investigated by R. Gjessing (28) for a considerable number of years. One day in the beginning of a psychotic phase he suddenly died. His death was explained by the histological demonstration of fat emboli in the myocardium. A careful clinical survey of the patient and study of his case record failed to reveal any of the usual sources of fat embolism, but a centrolobular fatty degeneration of severe degree was found in the liver which was assumed to be the source of fat emboli.

Psychotropic drugs used in mental depressions or acute psychoses have been shown to interfere with monoaminergic transmission in the brain. Since it is impossible to study the metabolism of these monoamines directly in the human brain, many studies have been made on the urinary excretion of these amines and their metabolites in various mental conditions. However, few conclusive results have been obtained, because only a very small part of the urinary monoamines and their metabolites derive from the central nervous system.

Psychotropic agents are widely prescribed. The effects of a drug represent a complex interaction between the chemical agent, the individual patient and the environment in which the administration of the drug takes place. Many patients use alcohol (a C.N.S. depressant) and control complex machinery. It is necessary to know how a drug interacts with alcohol and especially how it affects driving skills. Murray (1960), in a 90 day study of 68 drivers on chlordiazepoxide, found that traffic accidents were ten times more frequent than the predicted control rate. Zirkle et al. (1959) established that chlorpromazine had “a supplementary and possible potentiating effect” on the impairment of co-ordination and judgement produced by alcohol in 24 human subjects.

The purpose of this study was to investigate those entrants to a Ministry of Labour Industrial Rehabilitation Unit whose entry documents categorized them as “no disability” or “able-bodied”.

The case history is reported here of a woman who has developed involuntary movements while having prolonged phenothiazine therapy. The disorder has developed gradually and is apparently irreversible. It has some unusual features.

Reports of serious complications arising from the administration of amitriptyline have been very few, particularly when account is taken of the widespread prescription of this drug in recent years for depressive illness. This is a report of three cases of jaundice, one mild, one fatal, and the third severe, but leading to a good recovery, occurring following the administration of amitriptyline, though in two cases other drugs were being given concurrendy. The makers of amitriptyline do include in their literature a caution about the very occasional link with jaundice, but only two cases have so far been reported (Cunningham, 1965; Biagi and Bapat, 1967). In a recent article (Sherlock, 1968), no specific mention was made of amitriptyline in particular, or of tricyclic antidepressant drugs in general, as liable to produce hepatic disorder.

Recently there has been interest in the nocturnal sleep of the elderly. The studies by McGhie and Russel (1962), Weiss et al. (1962), Kales et al. (1967) demonstrated that, compared with young adults, elderly people have a reduced total sleep time, more awakenings following sleep onset and a moderate reduction in REM (rapid eye movement) sleep. In other words, elderly people have a more disturbed sleep. While this group have a shortened night's sleep, they are given to taking afternoon naps, and it may be that through these they can compensate for their insomnia at night.