In a recent paper (1, 2) Abse elaborates at some length the psychological aspect of cardiazol therapy, and suggests, among other things, that “asa result of repeated danger-situations and perceptual stimulation repression and organization (synthesis) follow as a psycho-biological necessity. The convulsion gives rise to objective anxiety and repression results, so that the ego, whose function it is, may deal with the situation. There may be factors (e.g. quantitative) which make this desirable conclusion impossible to establish… . The physician can exploit his relationship to the patient to the latter's benefit… . and he (the physician) can increase his knowledge of the operative conditions in the patient's life by observation of the pre- and post-convulsive episodes.”

In the literature the opinion is repeatedly expressed that Von Meduna's convulsion therapy, which is so frequently applied, is a comparatively harmless treatment, and that this method, provided the necessary precautions are taken, occasions more or less serious complications only in rare cases. This notion, however, is contradicted by the observations of others, as well as by our own experience. Lesions of the skeleton and affections of the lungs (putrid pulmonary abscesses and activation of latent tuberculosis) are first among the serious complications which may arise from convulsion therapy.

As a result of two operations which were performed on a rhesus monkey with the object of working out an approach for the destruction of the anterior nuclei of the thalamus, not only were the latter involved, but lesions were also produced in the frontal lobe. The lesions were largely caused by the removal of firm adhesions which had developed after the first operation. The motor disturbances and the mental changes which appeared after the second operation revealed some features which had much in common with a clinical syndrome previously observed in a patient who had died from a frontal lobe tumour in the same region. For this reason it seems worth while to record and to discuss these two cases. The experimental operations may be described in some detail in order to explain the extent of the lesions produced.

It is generally agreed that there are many objections to the use of cardiazol and azoman (triazol) as convulsants. The treatment is generally disliked and the injections are attended by much apprehension. There is frequently amnesia, though usually of a temporary nature. There may be some actual damage to the brain, fractures are not infrequent, and other complications sometimes occur. Old tuberculous lesions have been reactivated and deaths have occurred in status epilepticus from the use of azoman.

The investigation described below has as its object the determination of the influence of massive doses of insulin, such as are used in treatment of schizophrenia, on the concentration of the sugar and the ketone bodies of the blood with a view to analysing some of the causative factors of the symptoms of hyperinsulinism.

It is not surprising that the treatment of mental disorder should have brought in its train a clearer insight into the ordinary course of events in the human mind. In this as in every other department of medical experience the hidden processes of nature are revealed to advantage when they become manifest in some abnormal form. One has only to think of the importance of the part played by the recognition of heart-block and of muscular paralysis in elucidating the meaning of the successive phases of the cardiac cycle. In a wider field a greater claim can be made for clinical pathology in its contributions to knowledge of the structure and function of the nervous system. In the work of Hughlings Jackson (1) alone may be recognized the foundations of a new era not only of neurological medicine and surgery, but also in the more scientific spheres of anatomy and physiology. The subtle complexities that underlie the apparently even tenor of nature's average path may first come to light when disturbed by disease.

I am presenting to you in this paper my own views and experience in a practical psychotherapeutic approach to psychotics. I am aware—acutely aware—that I am speaking, with only two or three years' experience behind me, to distinguished psychiatrists. I cannot bring myself to apologize for having definite views on so short an experience; they are views that struck me before I had been employed in a mental hospital for a week, and I have had no occasion to change them since. I am not even sufficiently well up in the subject to know if they are peculiar to me.

Since Hildebrandt (1926) described the convulsant effect of cardiazol injection, several studies have been carried out on the mechanism of such convulsions. Zung and Tremonti (1931) suggested a direct action on the respiratory centre when cardiazol is used as a stimulant; Kerr and Antaki (1937) found no effect on brain glycogen or phosphocreatine in cardiazol-induced convulsions; Hashimoto (1937) found differences in distribution of calcium and potassium ions in the central nervous system after cardiazol. Goodwin and Lloyd (1938) recorded a direct effect on brain potential changes as shown on oscillographic records. Leibel and Hall (1938) found a large (75 per cent.) diminution of cerebral blood-flow at the onset of cardiazol convulsions. Weigand (1938) found no effect on liver glycogen or vitamin A content, reducing power of suprarenal cortex or blood picture. Denyssen and Watterson (1938) and Watterson and Macdonald (1939) attribute the convulsions to action on the vasomotor centre and note the action of vasodilator drugs in inhibiting convulsions. Wortis (1938) quoted by Quastel (1939) found no effect on brain respiration.

A small controlled series of cases of schizophrenia was treated with cardiazol at this hospital. A list of all those thought suitable for treatment was drawn up in order of date of admission and divided into two by selecting alternate cases. From the prognostic point of view there was little to choose between the two groups. The average duration of illness for all patients was six years. At the Berne-Munsingen Congress it was agreed that the remission rate falls rapidly with the duration of the illness, and that few cases of over four years' duration recovered with cardiazol treatment. This is also the opinion of others (1), (2), (3), (4), (5), (6), (7), (8), so no startling results were anticipated.

The purpose of this paper is to attempt to correlate results obtained from liver tests with the nosological demarcation of psychoses. The knowledge of the outstanding importance of the liver in general metabolism (it provides 12% of the turnover of energy of the body) and of its relation to some organic diseases of brain has been the subject of numerous investigations. Expectation of finding the starting-point of any disease in the liver, however, will at first not be placed too high if one recollects that every gland is only part of a system. Even where the symptoms of liver or other glandular impairment are characteristic for limited groups of psychoses deductions must be guarded, and the discovery of an unequivocal bodily symptom does not mean elucidation of the aetiology of a mental disease.

The senile psychoses are in regard to their origin an unsolved problem. Much valid work has been done in the field of anatomy and histology in approaching this problem, but as the mental diseases of old age cannot be separated from the growing old of body and mind generally, this problem is more or less a biological one. The borderline between old age and senile dementia is not a sharp one. In brains of old people without clinical symptoms of dementia there have been found histological changes, such as are usually found in cases of senile dementia. This makes it probable that the extent of degeneration of brain cells alone is not decisive for the appearance of senile psychoses. The finding of the characteristic plaques in the brain of senile psychoses may give evidence of the extent of the process and the severity of clinical symptoms, but it does not tell us anything about their nature and origin. Whether a constitutional factor is decisive or whether the histological changes are a reaction to an unknown noxa is undecided. Heredity may have its share too.

Epilepsy is as old as history. To the ancients it was a sacred disease, each convulsion signifying a visitation of its victim by one of the gods. Hippocrates first seriously attributed epilepsy to material causes, but the light of scientific approach which he momentarily kindled was soon extinguished, and for centuries the mysteries of epilepsy remained shrouded in a cloud of mysticism and religious cult, and if treatment was administered at all it usually consisted of incantations and spirit-exorcising rituals. In the modern era of medicine scientific battle has been joined with this disease in common with all others, and since the epileptic, like most other sufferers, is liable to an exacerbation of his disease in times of mental and physical stress, the present human warfare cannot but render more important than ever successes in the therapeutic field against epilepsy.

This paper represents a preliminary attempt to investigate some aspects of the influence exercised by the endocrine glands on the cerebral blood supply at various stages of development.

Much has been written about the possible somatic modifications that cardiazol, triazol and other convulsive agents bring about, and many investigations directed towards the elucidation of physical changes have been attempted. Such work in the materialist tradition of medicine is, no doubt, valuable. It would be unfortunate if it were to obscure other considerations.

The management and treatment of patients suffering from catatonia are constantly presenting a problem for mental hospital staffs, particularly in modern times, when more emphasis is laid on treatment than on custodial care.

The problem of making people suffering from catatonia into useful members of the hospital community seemed, from the very beginning, to be bound to fail, as long as the difficulty of inducing them to active and voluntary movements was not overcome.

This subject has a moderately extensive literature and examples have been recorded by various authors for some years. Most of the cases, however, have been the subjects of some pathological lesion, either congenital or acquired. Perhaps the earliest authentic case is the one originally described by Rosinius Lentilius in 1698, and quoted by Critchley, of a female, presumably young, epileptic sinistrad. The sex is not as important as the other factors, but it is a pity that there is no reference to the intellectual capacity. It is, if nothing else, a pointer to the usual type of case studied. In the adults, hemiplegics seem to have proved the most fruitful source for those collecting examples of this phenomenon, although a full list of causes is well known.