William Sargant

Treatment of Anxiety States by Antidepressant Drugs

Our thanks are due to the clinical staff of the Wolverhampton Group of Hospitals and of the General Hospital, Birmingham, as well as to the many general practitioners and consultants who have so generously helped us. We also thank the nursing staff and the administrative officers of these and many other hospitals in the district. Dr. Dorothy Parkin kindly undertook the serological typing, and Dr. J. A. H. WaterhoUse with his staff has given us much help and encouragement. Dr. J. Galloway and Dr. W. Weiner kindly helped us with records from their departments. We also thank the twins and their families for their patience and co-operation.

Observations on Benzedrine

Benzedrine was first introduced into therapeutics by Prinzmetal and Bloomberg (1935) for the treatment of narcolepsy. They found it more efficacious than ephe drine in bringing about symptomatic relief in this con dition, and their claim has.subsequently been confirmed. When they began their work little was known of the effects of the drug on man, though some physiological investigations had already been made on animals (Alles, 1933 ; Prinzmetal, 1933). In the same year Peoples and Guttmann made an independent study of its pharma cological actions at the Maudsley Hospital. Certain hitherto unrecorded psychological effects resulting from the administration of the drug to man were observed. In a preliminary report (Peoples and Guttmann, 1936) on these findings it was suggested that benzedrine might have therapeutic applications other than the treatment of narcolepsy. Numerous people have since experimented with the drug and a few have already indicated their findings, some workers confining their investigations to its use in depression, and others dealing with its wider psycho physiological actions (Guttmann, 1936 ; Myerson, 1936, 1937; Myerson and Ritvo, 1936; Nathanson, 1937; Solomon and Prinzmetal, 1937) ; one paper has specially stressed possible dangers and contraindications (Anderson and Scott, 1936). It is the purpose of this paper to report further per sonal observations of an experimental and therapeutic nature which have been collected since the preliminary communication on this subject (Peoples and Guttmann, 1936). Benzedrine has now been given to over 250 in patients, out-patients, and normal subjects at this hospital ; in a proportion of these only the subjective and objective results of administration have been noted, but in more than a hundred cases systematic experiments were carried out.

Physical Methods of Treatment in Psychiatry

No general practitioner can afford to regard psychiatry as a remote specialty of which he need know nothing. Psychiatric illness is far too common for that. It has been estimated that nearly half of the hospital beds in the country are occupied by psychiatric patients ; and about one-third of all the patients going to their doctors for help have symptoms which are caused or compli cated by psychological factors. Even if these patients are referred to hospitals or clinics they are likely to be handed back to their own doctors again. The family doctor is likely to be the last as well as the first court of appeal, especially when the patient has been seen by specialists of rival schools who have tendered mutually conflicting advice. The bewildered patient will then go to his own doctor, who, he trusts, will decide these com plicated questions for him on a basis of common sense. Furthermore, psychiatry depends on the general body of medical knowledge and opinion for guidance in making its advances. The family doctor knows which of his patients have benefited from one or another method of treatment. If in fact some theory of psychi atry proves of little practical use, its adherents, how ever fanatical their faith, will eventually be brought into touch with reality by a dwindling clientele. In the conference rooms of learned societies abstruse theories will continue to be debated in magniloquent terms. The wise practitioner will eschew theory but pay the closest attention to clinical facts, and judge from them alone. In this article methods of treatment are discussed which have no adequate theoretical basis. Their dis coverers were often led by theoretical notions which now no longer gain much credence. The reason why these methods are still used is because they are actually found to work. The lack of theoretical foundation cannot be claimed as a merit. But it mus? be remem bered that many of the most effective methods of treat ment in general medicine were discovered in the same accidental way?the use of liver extract to treat perni cious anaemia, for example. Much of our medical knowledge has been gained the wrong way round, and a discovery in therapy has compelled reconsideration of pathogenesis. Psychiatry to-day is in a stage of develop ment in many ways equivalent to that of general medi cine a hundred years ago, and we can expect advances to occur in the same way. The three methods of treatment discussed in this article have altered the face of clinical psychiatry. Before their advent the hospital psychiatrist had to watch the progress of his patients uphill or down almost with folded hands. Only in the case of the general paretic was he able to take active remedial measures. Since the discovery of insulin coma treatment, electric convulsion therapy, and leucotomy the outlook for the great bulk of his patients has been altered immeasur ably. This change has not occurred without putting new responsibilities on the general practitioner. It is now his duty to see that no one of his patients slips into a state of dangerous depression or mental alienation without being put in touch with the sources of aid. The several indi cations of these treatments are of immediate interest to all doctors who are directly in touch with and are directly consulted by the general public.

REACTION TO STRESS.

Orthopaedic Surgery in Infancy and Childhood. By Albert Barnett Ferguson, jun., BA., M.D. (Pp. 508 + xii; illustrated. £6.) Baltimore: Williams and Wilkins. London: Bailliere, Tindall and Cox Ltd. 1957. The editor and five contributors have included in one volume most of the subject-matter of orthopaedic surgery required in childhood. The acute phase of fractures is omitted, but a number of complications are mentioned. Reference is made to the observations and writings of British surgeons. There is a regional arrangement of the greater part of the text, but some studies, such as plastic surgery of the hand, are not in sequence. Affections of special tissues, such as bone and muscle, are collected in separate chapters. There is an up-to-date and clear description of the clinical and therapeutic features of most congenital and acquired conditions of childhood. Information on tuberculosis of the knee, hip, and spine will be found. The conception of metabolic disease is overshadowed by regional conditions, so that there is little evidence of the importance of studying a childs general health when spine, knees, or feet are brought to the doctors notice by the parent. However, the description of each condition is exactly what the general practitioner or aspiring graduate requires, and it is noticeable that the more recently recognized lesions appear to be regarded as of somewhat greater importance than wellestablished syndromes, such as birth palsy. The chapter on affections of bone, which is lavishly illustrated, will attract the readers attention in that the defective formation of bone from cartilage is a feature; and Robert Klein writes well on rickets and scurvy. Recommendations for treatment of congenital dislocation of the hip are made according to the childs age. The article on scoliosis is of some length and amply illustrated. The surgery of cerebral palsy, poliomyelitis, and progressive muscular atrophy is described. Readers may consider that the reproductions of a number of radiographs are insufficiently clear to exemplify the authors text. The book has a place in any surgical library, but it should be appreciated that it is not a complete textbook of orthopaedic surgery of children. ST. J. D. BuxroN.

Physical Treatment of Acute War Neuroses

an4 Conclusions The anti-Rh-containing serum of the mother of a baby which died of erythroblastic anaemia caused, when used undiluted, the agglutination of red blood cells of strongly positive reactors to anti-Rh, but failed, undiluted, to agglutinate more weakly reacting cells. When these weakly reacting cells were added to serial dilutions of the serum well-marked agglutination occurred if the serum was suitably diluted. These findings suggest the advisability of using a titration method before deciding that anti-Rh is not present in a serum, and in direct tests between the serum of a recipient and the red cells of potential blood-transfusion donors.

Ten Years' Clinical Experience of Modified Leucotomy Operations

Case 3.-Aged 53; post-menopausal. April, 1945, right mastectomy followed by deep x-ray treatment for breast carcinoma. January, 1947, right supraclavicular metastases treated by deep x rays. October, 1947, radiograph showed prominence of both hilar shadows and reticulation in the lung fields, diagnosed as lymphangitis carcinomatosa. January, 1948, stilboestrol, 5 mg. q.i.d., prescribed and continued; deep x-ray treatment given to pelvic metastases. August, 1949, decrease in size of hilar shadows, and lung fields appear clearer, although right diaphragm now raised. January, 1950, patient died, 27 months after the original lung metastases.

Treatment of Alcoholism.

NEUROPATHOLOGY Neuropathology. By J. G. Greenfield, M.D., F.R.C.P., LL.D., W. Blackwood, M.B., Ch.B., M.R.C.P.Ed., A. Meyer, M.D., W. H. McMenemey, M.A., D.M., F.R.C.P., and R. M. Norman MD., M R.C.P., D.P.M. (Pp. 640+ vi; illustrated. £5 5s.) iondon: Edward Arnold (Publishers) Ltd. 1958. This handsome volume is a comprehensive and fully illustrated study of all aspects of neuropathology except neoplasms. Apart from his editorship Dr. Greenfield wrote seven of the 13 chapters. These deal with the various infective and demyelinating diseases; the system degenerations of the cerebellum, brain stem, and spinal cord; trauma; diseases of the peripheral nerves ; lesions associated with diseases or malformations of the cranium and spinal column; as well as a more general and introductory chapter on the pathology of the nerve cells and neuroglia. In these important sections t-he mature experience of the author, based on a lifetime of routine work at the National Hospital, Queen Square, is crystallized. Posterity will be grateful for those more spacious years of his retirement that enabled Dr. Greenfield to undertake this labour, and our sole regret must be that he did not live to see and handle the product of his work. Dr. Blackwood contributes a useful chapter on the vascular diseases in relation to the central nervous system. That by Dr. Norman deals with congenital malformations, the effects of birth injury, and neonatal diseases. This is an important and particularly well illustrated section, which is most welcome, from an acknowledged expert in this field. Professor Meyer has written on anoxia, intoxications, and metabolic diseases. He and Dr. McMenemey are separately responsible, too, for different aspects of the dementias, psychoses, and epilepsy. In general, Dr. Greenfield has been ably supported by his team, and the synthesis collectively reflects a high order of accuracy and scholarship in which the reader is brought up to date without loss of historical perspective. Each chapter has its own list of references and separatd enumeration of the illustrations, but altogether there are about 500 of the latter. The text is laid out so readably and tersely that it is easy for reference as well as more extended study. It is safe to predict that the work will prove indispensable for all specialists in this field, whether pathologists or clinicians. DOROTuy S. RUSSELL.

Depression and Leucotomy

If, rightly or wrongly, one accepts the theory that intrauterine devices, both ancient and modem, act as disnidators, then they are not contraceptives but abortifacients, and the incidence of extrauterine gestations in those women who have been fitted with these devices should remain unaffected. Mr. Ramkissoon-Chen and Dr. Kong Ta-Ko have issued a timely warning that in these cases the symptoms produced by a tubal gestation may easily be mistaken for sideeffects due to the intrauterine device. In underlining this warning I hope that the diagnostic pitfall will be widely appreciated in order that occasional serious complications may be avoided.-I am, etc.,

Drugs for Depression

of the abdominal pain. Obviously patients who suffer from chronic headaches, from whatever cause, must be considered on their merits. In this respect it is worth mentioning that Mr. Hannas second case of appendicitis, for which he could discover no urinary cause, developed a severe headache 12 hours after the onset of the abdominal pain (personal communication). With these provisos, however, I reaffirm that I have never encountered a true headache that coincided with the onset of the abdominal pain in a case of uncomplicated acute appendicitis.-I am, etc., St. Austell, Cornwall. D. G. WILSON CLYNE.

Hess's Mental State

This book has as its main medical interest a fairly full discussion of Hesss mental state during his long stay in England and at his subsequent Nuremberg trial. Though some psychiatrists would consider that Hess was suffering from a paranoid schizophrenia, with at times some confusing hysterical symptoms, it seems that the diagnosis of schizophrenia was never officially made. Apart from the psychiatrists who examined Hess, Lord Beaverbrook was called in early by Churchill to give an overriding and common-sense psychiatric opinion; he reported Hess as quite sane. However, Hess was obviously psychiatrically ill at his trial. Though the severity of his illness was not fully admitted, he did avoid the death penalty at Nuremberg. He is almost certainly still mad in Spandau jail to-day. With mainly official sources and pronouncements to rely on, the author of this book also makes out that Hess was really pretty sane while in England and was mostly putting it on. The Russians shared this viewpoint. It shows how the facts of history can so often be misjudged for posterity. Fortunately there are ample clinical descriptions in this and other books of Hesss many and complicated delusional systems, and of his hallucinations and other psychiatric abnormalities, so that future medical men will have a lot of factual data available to judge for themselves. WILLIAM SARGANT.