In a preliminary report (Brit. Med. Journ., 2, 310, 1940), two modifications were introduced in Sakel's technique for the insulin treatment of schizophrenia, with the primary object of continuing the treatment under wartime conditions. The first and most important of these was concerned with the saving of sugar. This simple method, by which glucose is given intravenously and is followed by a drink of potato soup as soon as the patient is awake, has already been fully described by us. We discovered incidentally that this method effected a saving of insulin amounting to 46.6 per cent. in seven patients. Various critics have asked why other workers have not effected a saving by using intravenous insulin. Further, we have been asked what advantages are to be gained by giving insulin intravenously apart from this saving of the drug; whether intravenous insulin adds any dangers to the treatment, and whether it brings about a remission in schizophrenia comparable with intramuscular insulin. We have had more than a year's experience with the use of intravenous insulin, and this paper aims at describing our first year of this experience and answering the questions set out above. We may mention that in 24 additional patients treated, an average saving of 28.3 per cent. of insulin has been effected.

In 1936 Tomesco (1) and his co-workers described changes in the crystallization of sodium chloride produced by the addition of small amounts of cerebrospinal fluid to 0.8 per cent. saline. A drop of *8 per cent. NaCl solution dried on a microscope slide at 75° C. produces a thin circumference of crystals surrounding an empty space. If normal C.S.F. is added in proportions of 1 C.S.F. to 20, 40 or 60 parts saline the central empty space is replaced by a thin translucent film of crystals, which in the higher dilutions begins to show lacunae. In a dilution of 1 in 120 this translucent film is reduced to a narrow strip along the inner margin of the circumference. Microscopically the translucent area is found to consist of concentric circles, feather- or spear-shaped crystals, parallel lines, needles, etc., well organized in the low dilutions, but not organized in a dilution of 1 in 120. This is regarded as the normal crystal picture.

The literature relating to mongolism is extensive and for the present purpose it need not be reviewed. The hand has been mentioned in almost every study on mongolism. Crookshank (1931) has given it an important place in his provocative book, The Mongol in Our Midst, without enlarging our knowledge of the now familiar features in shape and crease lines of the hand. Penrose mentions in The Creases on the Minimal Digit in Mongolism (1931) that in a certain number of cases one crease line on the fifth finger is lacking, which makes the fifth finger look almost like a second thumb. Very recently Harold Cummins of the Tulane University, U.S.A., observed a certain anomaly in the dermatoglyphs of the hands of mongoloid imbeciles (1939). He comes to the conclusion that in the finger-tips of these hands there is a noteworthy reduction in the occurrence of the whorls, and that of the five palmar patterns, hypothenar, second interdigital and third interdigital patterns are increased in frequency, while thenar/first interdigital patterns are less frequent, and also that frequencies of hypothenar types depart widely from the normal. C. E. Benda mentions that ossification of the carpal and long bones is early and that growth of the bones comes to an early end; this might account for the short hands in mongolian imbeciles (1939).

Whereas fall of body temperature is always a danger signal in ordinary starvation and only occurs just before the end, in hypoglycaemia changes of temperature take place in an early stage parallel with the characteristic neuropsychiatric signs. Many workers (Sakel, Gellhorn, Fortuyn and others) have observed and commented on the drop of temperature in coma. The present paper is an attempt to describe the fluctuations of temperature during insulin treatment of psychoses and their correlation with the clinical signs of hypoglycaemia and to discuss their significance.

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.

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).

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.

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.

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.