Unhydrolysed urine does not usually give a strong Millon's reaction in healthy people, but various workers have reported a strongly positive Millon's reaction in the unhydrolysed urine of mentally defective patients. Schemer (1927, 1928) worked up such urines for tyrosine with negative result, and also showed that the reaction was not due to free phenol or oxy-acid. He claimed (1929) to have isolated the substance responsible, but did not identify it. Lieb and Schadendorff (1929) showed that the substance isolated was impure sodium acetate formed in the method of isolation. The mystery of the substance giving the Milon's reaction was thus left unsolved.

Since the passing of the Mental Treatment Act in 1930 it has been noticed that a number of patients who have been discharged recovered from hospital seek readmission as voluntary patients within a comparatively short time of their discharge.

The behaviour of animals and man may be approached from many points of view, but there is one feature of their behaviour which is outstanding in its importance and in its difficulty. I refer to the peculiar “adaptiveness” of animals' behaviour. The concept is vague, but everyone knows, roughly at least, what is meant by it. It is certainly one of the most remarkable features of animal behaviour. In psychiatry its importance is central, for it is precisely the loss of this “adaptiveness” which is the reason for certification.

The nature of the action of insulin in producing cure in cases of schizophrenia is still quite obscure. One of the most striking features of insulin hypoglycaemia is the occurrence of phenomena pointing to disturbance of the autonomic nervous system, and many authors on this subject have expressed the belief that insulin produces cure by virtue of its action on the autonomic nervous system. There is, however, extensive contradiction in the literature as to what actually are the changes which take place in autonomic functions during hypoglycaemia. Some authors say that hypoglycaemia produces a generalized sympathetic stimulation, some say a generalized parasympathetic activity and others that there is dissociation of action of the two systems. Sakel (1) appears to believe that hypoglycaemia produces a vagotonia which underlies the curative effects of his treatment; Hadorn (2), that small doses of insulin stimulate the vagus, and large doses cause a primary secretion of adrenaline; Beno (3), that changes on the vegetative system cannot be sufficient to allow a reasonable understanding of the results; Pfister (4), that hypoglycaemia produces beneficial effects in schizophrenia because it damps the sympathetic; Wespi (5), that dissociation appears to prevail in the autonomic regulation; Gellhorn (6), that the treatment is successful because it leads to excitation of the sympathetico-adrenal apparatus through hypoglycaemia of the brain; and lastly, Heilbrunn (7), that his experiments are in favour of a sympatheticotonia.

During the course of research into an improved method of the Meinicke Klärungs Reaction (Ford Robertson, W. M., and Colquhoun, D. B., 1939) certain undesirable zone reactions occurred. This paper deals with some of the factors responsible for such non-specific precipitations.

There has been an extensive literature on accidents occurring during cardiazol treatment, and since the largely conflicting pathogenic view-points have been discussed in recent reviews (Gross and Gross-May, 1939; Kennedy, 1940; Wyllie, 1940), there is no need for their detailed enumeration. Gross and Gross-May, whose paper was unfortunately not available to us in the original, recently summed up the more important causes of accidents, grouping them into mechanical disorders, particularly of the osseous, tendinous and muscular system; disturbances of the vascular system—arrhythmia, auricular fibrillation, syncope and vascular spasm due to the specific action of cardiazol; and finally, respiratory disturbances—arrest of respiration, pulmonary embolism, and abscess due to thrombophlebitis at the site of injection.

Treatment by convulsion therapy implies the administration of analeptic drugs in massive doses to induce major epileptiform convulsions. Usually a single convulsion is induced on each occasion and this is done two or three times weekly. The number of convulsions varies greatly in different cases, but is commonly from five to twenty.

It is not uncommonly believed that convulsion treatment produces its successes mainly or entirely through the fear which it engenders. This opinion, more often implied than definitely stated, has been crystallized by McCowan (1), who boldly wrote:

“No reasonable explanation of the action of hypoglycæmic shock or of epileptic fits in the cure of schizophrenia is forthcoming, and I would suggest as a possibility that as with the surprise bath and the swinging bed, the ‘modus operandi’ may be the bringing of the patient into touch with reality through the strong stimulation of the emotion of fear,” and “that the intense apprehension felt by the patient after an injection of cardiazol, and so feared by the patient, may be akin to the apprehension of the patient threatened with the swinging bed. The exponents of the latter pointed out that fear of repetition was an important element in success.”

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.”

It is proposed, firstly, to summarize some anomalous cardiac occurrences observed and recorded by the writer in a series of seventy-five cases which underwent treatment with cardiazol for various types of mental illness in the mental observation wards of the Southern General Hospital during the period November 11, 1938, to April 30, 1939; secondly, to suggest an explanation for the occurrence of these anomalous cardiac occurrences, hereinafter referred to for the sake of brevity as abnormalities.

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.

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.

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.