I chose the title “Watchman, What of the Night?” because I hope to show that “the night is departing, the day is approaching”.

When I was thinking, with considerable anxiety, how I should start this address to you I was at the same time listening to the anthem by Brahms: “Blesseadre they that mourn”. Surely this omen was a good omen. How ever I may mourn to fall short of the high standard you are accustomed to, you will I trust bless and comfort me by your kind-hearted and friendly reception of my effort.

More than a thousand years ago a Japanese writer, we are told, came to the conclusion that specialism was the curse of every subject in connection with which it had been developed.

I would first like to thank you for the honour and privilege of addressing you on this subject of co-operation between special departments of a general hospital.

My remarks in this paper are based on two inquiries I have made into the case material with which I dealt while I had charge of one of the weekly Out-Patient Departments at The Lady Chichester Hospital.

The advantage and desirability of early treatment in all forms of mental disorder are now generally accepted. The treatment of general paralysis of the insane by malaria, of schizophrenia by shock therapy and of the neuroses by psychotherapy covers a wide range of different methods, yet no one would hesitate to stress the importance of starting the treatment in each case as early as possible. Nor must the necessity of prophylaxis be forgotten, with the consequent importance of child guidance.

Outline of physiology of sympathetic nervous system and its effect on the cerebral blood-vessels. Other factors controlling cerebral blood-vessels, such as local intra-arterial pressure and gas tension. The action of adrenalin-like and cholin-like substances on the cerebral blood-vessels. Alteration in cerebral blood flow during a convulsion, and the accompanying changes in cerebro-spinal fluid pressure. Evidence for systemic sympathetic disturbance during a convulsion. Discussion of “vaso-vagal” attacks and “diencephalitic” epilepsy.

(1) The diurnal water exchange has been studied in two patients for approximately four months, and in a third patient for one month. Similar measurements were made on two non-epileptic patients as controls. No certain evidence was obtained that the urinary excretion was decreased before a fit and increased afterwards, as has been often claimed. The water balance has been determined daily as completely as is practicable and the method for this is described. The daily excretion of chloride in the urine under constant salt intake at two levels has also failed to show any relation to the incidence of fits.

(2) Serial investigations have been made of the concentration of constituents of the blood which might be affected by changes in the water content of the organism, viz., protein and non-protein nitrogen in the plasma, hlemoglobin and total solids in the whole blood. Here again the variations are apparently unconnected with the incidence of fits, contrary to the findings of other authors.

It is not known to what extent convulsions induced experimentally by various agencies are related pathogenetically to epileptic fits. There are, however, facts which suggest that the induced convulsions have, in their several mechanisms, points in common with one another and with epilepsy. Thus, caffeine and absinthe both cause convulsions in cats; when sub-convulsant doses of both are administered together convulsion ensues, suggesting that the two drugs operate on the same mechanism (Notkin and Pike, 1931). Insulin hypoglycæmia occasionally causes convulsions; it has been shown that during hypoglycæmia in man there is a lower fit-threshold to cardiazol (Georgi and Strauss, 1938), and in cats to thujone (Keith, 1935). The elicitation of convulsions by electrical stimulation of the cortex is facilitated by camphor monobromide, absinthe (Muskens, 1928), and cardiazol (Santha, 1939) on the one hand, and in epileptics as opposed to non-epileptics, on the other (Pen-field, 1936). Hydration has been shown to play a part in the precipitation of convulsions due to hypoglycæmia (Drabkin and Ravdin, 1937), thujone (Keith, 1935), and epilepsy (Fay, 1929; MacQuarrie, 1929).

The electro-encephalogram (E.E.G.) is a record of the electrical potential changes of the brain as recorded by placing electrodes on the scalp without opening the skull. The technique is similar to that used in obtaining a electro-cardiogram, and in the apparatus shown three independent recorders are used, for reasons to be described later.

In round figures there are 11,000 epileptics in public mental hospitals, 3,000-4,000 in institutions for mental defectives, just under 4,000, who are neither insane nor mentally defective, in colonies and residential schools, and an unknown number, probably a considerable one, in public assistance hospitals and institutions. How many are living in the community is not known.

In this short paper I hope to present to you some of the problems attendant on the employment of the epileptic. In so doing I shall rely as far as possible on my personal experience of the problem as it has presented itself in my routine work as medical officer for the London district of the L.M.S. Railway, which covers a large area of our system, with some 44,000 workers employed on a wide variety of occupations.

Attention was drawn to the important work of Putnam and Merritt by an annotation in the Lancet last year. The results of their studies were published in two papers entitled “A New Series of Anti-convulsant Drugs Tested by Experiments on Animals” and “Sodium Diphenyl Hydantoinate in the Treatment of Convulsive Disorders”.

Although the subject of this contribution is somewhat narrow, it is hoped that points raised will have some bearing on matters wider than pure therapeutics.

The present communication is a preliminary report on 12 certifiedcases suffering from insanity with epilepsy treated with solantoin, a preparation of sodium diphenyl hydantoinate. This paper also discusses the site of action of the drug, and the possible relationship between its excretion and toxic effects.

Within the last few years advances have been made in research in epilepsy which have resulted in new hope for the sufferer and physician alike.

It is just twenty years ago that I read a paper on the “Problem of Psychogenesis in Mental Disease” before this Society. William McDougall, whose recent death we all deplore, was in the chair. What I then said about psychogenesis could be safely repeated to-day, for it has left no visible traces, or other noticeable consequences, either in text-books or in clinics. Although I hate to repeat myself, it is almost impossible to say something wholly new and different about a subject which has not changed its face in the many years that have gone by. My experience, however, has increased and some of my views have matured, but I could not say that my standpoint has had to undergo any radical change. I am therefore in the somewhat uncomfortable situation of one who, on the one hand, believes that he has a well-founded conviction, but, on the other hand, is afraid to indulge in the habit of repeating old stories. Although psychogenesis has been discussed long ago, it is still a modern, even an ultra-modern, problem.

The difficulties inherent in reducing schizophrenic thinking to the conditions of an experiment have led to a variety of attacks upon the problem. Of these, the attempts to subject thinking disorders to methods of quantification have so far yielded little of value. That this has been the case can be readily understood when one considers what heterogeneity of psychopathology is included under the term “schizophrenia”. Moreover, the thought of schizophrenics is apparently of the same order of complexity as the thought of normal persons, and its qualitative characteristics are even less well known. Under present conditions the qualitative approach seems to promise a greater and more useful field. Where tests have been employed with advantage in studying schizophrenia it has been chiefly their by-products that have deserved attention.

Though detailed knowledge of the autonomic nervous system is comparatively recent, the initial conceptions of its nature have undergone very important modifications during the time it has been known. This is mainly due to the fact that originally the anatomical discovery was taken up by investigators in various branches of clinical medicine, physiology and pharmacology, and made a special subject for detailed research. Especially did the dualism which is so remarkable a feature of the autonomic nervous system give rise to a number of theories about the relationship of the two components.

In talking to delirious patients I have observed a curious and characteristic phenomenon: the patient, in spontaneous conversation, addresses me as “Doctor”, yet when the very next moment I ask him my vocation he cannot answer correctly. I propose to show that this is not merely a capricious phenomenon without meaning, but that it demonstrates the soundness of one of Hughlings Jackson's most important principles. I have observed the phenomenon in no less than nine cases of delirium, and more than once in several. Three cases will serve as examples.

This communication, notwithstanding its title, does not pretend to be anything in the nature of an exhaustive comparison of the respective merits of triazol and cardiazol in the convulsion therapy of schizophrenia.