It has been recognized for at least 150 years that the organization of wards in public institutions often “results in a lack of adequate attention, provides an unnatural environment and promotes neglect, abuse, injuries and confusion”, Noyes (1953). The atmosphere of the mental hospital back-ward, so different from that existing in the patient's home, creates a social, psychological and physiological “vacuum” and is particularly unfavourable to the long staying schizophrenic patient, who, as a result shows a progressive deterioration in habits and social relationships.

An early remedy practised at the York Retreat (Samuel Tuke, 1813) was that the nurses, having gained the patients' confidence, should attempt “to arrest their attention, and fix it on objects opposite to their illusions; to call into action as much as possible, every remaining power and principle of the mind; and to remember that, in the wreck of the intellect, the affections not unfrequently survive.”

One and a half years after she had been excluded from school a little girl of six and a half years was being watched by me as she took her part in the school assembly and entered into the normal activities of the A stream of her class. Some two months later the head teacher telephoned us excitedly to say that this same child had put up her hand in the full school assembly and answered the question correctly. There is perhaps little remarkable in this until I add that this child, Gwen, in October, 1952, was diagnosed as a schizophrenic and has, with two others, been treated along the lines indicated in a previous paper.∗

Largactil is one of the phenothiazine group of compounds. It is, therefore, related to promethazine (phenergan) and diethazine (diparcol). It is also known as R.P. 4560 and chlorpromazine. It has been used on the Continent in psychiatric cases since 1951, because of the relaxation and calm it produces. It has been on trial at Netherne Hospital since 1953 and 80 patients have received this treatment.

That variations of blood-pressure are found in states of emotion is commonplace knowledge; that rises may take place with temporary fear and anxiety is also well known, but that anxiety occurs with a reduced or normal blood-pressure is not perhaps so well appreciated.

The purpose of the present investigation was to determine whether the blood-pressure remains high when the patient with anxiety is in a state of overt placidity and calmness.

As an approach to the problem of schizophrenia it is proposed to compare the effects and after-effects of severe hypoglycaemia due mainly to islet-cell adenoma of the pancreas in otherwise healthy people with the effects and after-effects of severe hypoglycaemia therapeutically induced in schizophrenics.

The difficulties are plain. Personal experience of patients with functioning islet-cell adenoma is limited almost always to a few cases, whereas average experience of insulin coma treatment covers some hundreds of cases; moreover, there is little overlap of experience except in the post-mortem room or in the laboratory for morbid histology. During insulin treatment there is constant supervision by a trained staff, medical and nursing, so that serious developments can be met by immediate intravenous sugar and investigations are continual; with adenomata there is no observation until, perhaps, a general practitioner is called in about alarming symptoms of one kind or another and sometimes months or even years elapse before a patient gets into hospital, where the intensity of observation and even more so of investigation may exceed that available in mental hospitals. Insulin coma treatment has a more or less standard aim, to produce coma of increasing duration up to a maximum of something like an hour which is then repeated thirty times or more; dosage is built up with the greatest care. Adenomata produce conditions varying from the hardly serious to the fatal under the influence of an insulin dosage which is quite unknown.

This comparison is based chiefly on an analysis of 290 serial courses of insulin coma treatment given to schizophrenic patients at Holloway Sanatorium during the four years 1950 to 1953 inclusive, and on the 258 cases of islet-cell adenoma reported by Crain and Thorn (1949) and the 398 cases, all that could be traced up to that date and including the Crain and Thorn cases, analysed by Howard, Moss and Rhoads (1950). Many separate papers have been consulted for more detailed approaches and for extra information, although of course those published before 1950 were included in the reviews already mentioned. Despite the difficulties of this comparison, it can be shown that the similarities between the two groups follow expectation and are very strong indeed, so that the differences which emerge have at least possible significance.

During recent years a number of Local Education Authorities have opened Hostels for Maladjusted Children but few have been open long enough for any adequate review of their work to be undertaken, or for principles of working to be clearly formulated. Winnicott and Britton (1944, 1947) have discussed their work in Hostels for evacuated children during the War, and the Ministry of Health (1944) also reviewed their war-time experience in similar Hostels. Little however has been written on the work of Hostels for Maladjusted Children as part of the ordinary peace-time work of a Child Guidance Service. This paper reviews the work done during the five years 1946 to 1951 in two Hostels in a Midland City and comments on the experience gained. It is felt this may be of general clinical interest, and of value for comparison with observations being made in other areas. As part of the review a study has been made of 50 unselected children who, having been in the hostels, had been discharged during that period, and whose subsequent progress it has been possible to follow.

The last thirty years have witnessed the rise and fall of many theories and therapies on a supposed relationship between psychiatry and endocrinology, and perhaps the time is now ripe to weigh the evidence and attempt to draw at least tentative conclusions. A clear picture of an existing situation not only often leads to improved understanding but also to greater clarity of purpose.

It has long seemed apparent to workers in the child guidance field that many of their patients show evidence of longstanding emotional disturbance; either the symptoms now complained of have been present for many years, or there has been a history of symptoms earlier on which have disappeared only to be replaced by the existing ones. Some of these patients whose present condition may be almost intractable, might have been helped had they been treated at an earlier date, while recent work by Bowlby (1951) and others has emphasized how important are security and satisfactory emotional relationships in the early years for the establishment of a stable personality. Thus it appears that any prophylactic approach, aimed at reducing the incidence of emotional disturbance in older children, and it is hoped ultimately in adults, may need to be made very early in life.

Little has been published, apart from accounts of individual patients, of work on any series of very young children who were psychiatrically disturbed, particularly from a prophylactic point of view. Joseph (1948) has described some of the patients she has seen in a child guidance clinic attached to a child welfare centre, and Gillespie (1954) has compared the symptomatology of a series of pre-school children treated at Infant Welfare Centres with the preschool histories of older children treated in a child guidance clinic. She points out that the type of problem dealt with in the under-fives was seen in a high proportion of the earlier histories of those who needed treatment at a later age. The importance of early treatment for parents in the prevention of serious disturbance in the children has been emphasized by Fries (1946) by Jacobs (1949) and on a community scale by Caplan (1951). His experience in Infant Welfare Centres in Israel over a number of years has led him to concentrate on the treatment of cases where abnormal symptoms were not yet manifest, but where pathogenic relationships of the parents to the child were such that he felt that emotional difficulties in the child might later develop. In this country such a prophylactic approach is relatively unexplored, although the possibility of preventing mental ill health in children is one which has interested public health authorities for some time.

“No man is an iland, intire of itselfe; every man is a peece of the Continent, a part of the Maine; if a Clod bee washed away by the Sea, Europe is the lesse, as well as if a Promontorie were, as well as if a Mannor of thy friends or of thine owne were: any mans death diminishes me, because I am involved in Mankinde. And therefore never send to know for whom the bell tolls; it tolls for thee.”—John Donne.