The distribution of the blood-groups in persons suffering from mental disease has been widely investigated, but the literature is full of conflicting statements. It may fairly be taken that no one has yet demonstrated any statistically significant alteration of the blood-group distribution in any other disease, but there have been many claims for variation in mental diseases.

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.

Truant is an old French word meaning “vagrant”, and the term “truancy” means “unlawful absence”. The study of truancy in children is chiefly concerned with wandering, staying out from home, and staying away from, and refusing to go to school.

The development of the concepts underlying the terms mental deficiency and psychosis with mental deficiency, may be arbitrarily divided into four periods, which to a considerable degree, overlap. The first period is concerned with the separation of the two principal groups, mental deficiency and mental disorder. Even before the time of Hippocrates some differentiation had been made between the idiot, who was feeble-minded from birth and the dement, who had deteriorated from a previously normal status. Pinel (1), however, as late as 1806 used the term idiocy loosely, and included many cases of terminal dementia and other deteriorated states. The end of the first period is marked by the definitive separation by Esquirol (2), in 1828, of mental defect and mental disorder, but it was not till 1886, in England, that a legal differentiation was made been insanity and feeble-mindedness.

Ladies and Gentlemen,—I have to acknowledge with grateful appreciation the honour you have done me in electing me to the Presidency of this Section.

I recall that my immediate predecessor, in his learned address from this chair, deplored the slow progress of psychiatry in the last half century. He stressed the necessity for intensive research in many directions. As I listened to him I felt that there was one supreme need in psychiatry, and that need was the co-ordination of biological and psychological views. As it seems to me, we have an increasing volume of research proceeding on these two lines, yet the lines never seem to meet. The psychologists pour out an incessant stream of literature, equalled only by the joint efforts of histologists, biochemists, neurologists and the rest. But what psychopathologist would bring himself to refer to Alzheimer cells, or what biochemist could make mention of an Œdipus complex? Yet in some of our patients—perhaps in most, if not in' all—such factors co-exist. I venture to express the hope that during this session our discussions may elaborate the leitmotif of synergic ietiology.

We have previously investigated the blood-group distribution in a series of normal persons and mental patients and shown that there is no significant difference between the two groups (Thomas and Hewitt, 1939). As an ancillary procedure in the investigation of any possible differences in the serological make-up of persons suffering from mental disease, we have determined the iso-agglutinin titres in a similar series of normal and mental patients. On prima facie grounds no difference is to be expected, and in the result, no difference was found.

The published reports on convulsant drug therapy of the psychoses have stressed the favourable results of such treatment, with only an occasional reference to the undesirable or unfavourable sequelæ other than such complications as fractures, dislocations, cardiac arrhythmias, etc. It seems worth while to survey the results of a series of patients so treated, and point out that psychotic patients receiving convulsant drug therapy may show undesirable mental sequelæ.

To the student of mental deficiency the lower grades of oligophrenia offer endless opportunities for the exercise of his diagnostic acumen, and in this largely unexplored terrain there are doubtless many syndromes awaiting discovery.

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.

From a clinical point of view, mental deficiency and insanity are usually considered to be separate disorders. The members of each group who require institutional care are collected in separate hospitals and the methods of treatment are on different lines.

The insulin treatment of schizophrenia has been practised at Hatton since June, 1937. The Vienna technique has been employed, with certain modifications described in a recent paper in this journal by Gillman and Parfitt.

The literature on the drawings of schizophrenics is mainly concerned with their spontaneous artistic production. Some schools of psychotherapy use drawings systematically as an approach to the patient, i.e., as another way of obtaining free association from them. But apart from this, little work has been done on experimental drawing for diagnostic purposes. There is, however, the interesting work carried out by Mohr (1), who analysed drawings of mental patients of various kinds, and demonstrated in their production numerous clinical symptoms. His paper, classical as it is, has not stimulated many others to follow his lines. Sapas (2) collected systematically drawings of mental hospital inmates, which, in fact, were tests of visual memory. She followed, in her investigations, the technique originally proposed by Hickson in his work on The Mental Fingerprint. Lately, Becker (3) has contributed to the problems involved, in a systematic study, which will be referred to later.

As the title suggests, this paper is a review of insulin therapy in our hospital, and as such we shall discuss only actual cases with their results.

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.

During the last century the fact that two people share a psychosis has been recognized as constituting a problem of psychiatry. Although quite a number of cases have been published, we were surprised at the relatively small number. The subject lends itself admirably to systematization, and the classification which has been accepted by most writers is the one evolved by French authors.

Insulin shock treatment of schizophrenia is to-day a recognized part of our therapeutic armamentarium in mental disease, and with selected cases is yielding results which are more encouraging than those given by other methods. At the same time the method is largely empirical, and the theories of its mode of action are only equalled in number by the hypothetical causes of the disease itself.

From the use of insulin in the treatment of schizophrenia much has been learned about hypoglycæmia, but nevertheless the physiopathology of the subject remains obscure. The intricacies of the ætiology of hypoglycæmia are well illustrated by Martin and Hellmuth's (1) study of 404 patients uninfluenced by insulin. The blood sugar in the majority of these cases was found at some time to be below 70 mgrm. %, and only in about one-third was an organic basis ascertained. Only 9% had definite symptoms of hypoglycæmia, 71% were asymptomatic and 20% were suggestive. The blood-sugar levels at which symptoms occurred differed in different individuals. Those showing symptoms at comparatively high levels belonged mainly to a group described as “symptomatic functional hypoglycæmia “, and those showing symptoms at lower levels were mostly suffering from psychoneurotic disorders. Martin and Hellmuth consider that few of these cases should be diagnosed as suffering from “hyperinsulinism” as described by Seal Harris (2) and Ross and Josephs (3).

(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.

In a social system where responsibility for the care and support of children rests with the parents, society is justified in imposing restrictions designed to prevent the births of children to a socially incompetent person who is unable to assume such responsibility. Owing to the overcrowded conditions of state institutions for the care of the mentally defective, it is certain that patients committed to such institutions are scarcely able to provide satisfactory care and support for themselves, and would not be able to provide adequately for any children that they might produce. On this basis, society is quite justified in enacting the regulation, as, according to Popenoe (1, 2), has been done in one State, that no patient who has been committed to a state institution for the care of the feeble-minded shall be allowed to leave the institution without having first been sterilized.

A brief note upon the physical characteristics of three cases of phenylpyruvic oligophrenia may be of interest for comparison with other cases. The three patients have been under special observation for 2½ years, and are the only definite cases discovered in an examination of 2,300 mental defectives of both sexes, all ages and all grades.