My problem is to give you a short review of some investigations we have undertaken at Dikemark Mental Hospital on the disturbances of somatic functions in catatonia with a periodic course (1).

The hippuric acid excretion test (after benzoate administration) has been used by previous workers, with the general result that it affords a reasonably accurate and satisfactory test for determination of parenchymatous hepatic damage and of various hepatic involvements. The test is also known to be indicative of hepatic disorder, even where no clear clinical signs of hepatic or renal derangements are observable. A series of 67 cases of mental disorder has been examined by the test, 45 of which belonged to the schizophrenic group; 18 of these were classed as catatonics. The average value of hippuric acid eliminated in the non-catatonic schizophrenic group, expressed in terms of benzoic acid, in 4 hours after administration of 6 grm. of sodium benzoate, was 3.4 grm. with an average deviation from the mean of ± 0.4 grm. This value agrees well with the values obtained by previous workers for normal cases having no hepatic damage. The average value of hippuric acid eliminated under the same conditions by catatonic patients was 2.2 grm. with an average deviation from the mean of ± 0.5 grm. All the catatonic patients studied, without exception, showed a diminished ability to excrete hippuric acid at a normal rate. It is inferred that a metabolic disturbance of the liver affecting benzoic acid detoxication may be a characteristic feature of catatonic patients.

Work on benzoic acid detoxication in catatonic patients before and after various shock treatments for schizophrenia is in progress.

When, a few months ago, your Association honoured me with its invitation, I undertook the task of presenting to you the results of the first 100 cases treated in the Clinic in Vienna. I intended to draw from the individual reactions and the effect of the therapy some conclusions as to its justification. I could also have brought forward conclusions drawn from the records of cases whose treatment has been terminated for a long time and who have remained under continuous observation. These results would have been of some value inasmuch as these would have referred to the cases which I myself treated individually, and in which treatment had been individualized by employing various types of shock.

Pace Mr. Punch, we know that there are plenty of takers, and anyone who uses convulsion therapy soon becomes convinced that much good is achieved in one way or another. Moreover, it has become evident that the treatment is not applicable to schizophrenia only; some striking results are seen in depressive states and in atypical paranoid and obsessional cases. This matter is dealt with at length in Dr. Cook's paper. These results, together with the comparative ease of application of the treatment, suggest that it will inevitably be tried out on a very large scale indeed.

In a 15-minute contribution it is only possible to deal with a single aspect of cardiazol therapy. I am confining myself to some observations on the diversity of mental reactions influenced by cardiazol convulsions. My remarks are based on approximately 130 complete courses and a number of incomplete courses given at Bexley Hospital during the last 12 months.

All those who have worked with insulin will have been impressed by the great freeing of behaviour that the patients exhibit. It is seen in the hypoglycæmic state, before coma sets in, and as the patient returns to consciousness after interruption of the coma. The degree of this freeing varies directly with the prognosis. In this uninhibited state the anatomy, the very bones of the personality, can be studied, and the physician's observations should be able to establish the main outlines of the pathology of the total personality—the psycho-pathology.

In 1933 Sakel described the induction of epileptiform convulsions during hypoglycæmia, using camphor and cardiazol. This was not, to my knowledge, followed up systematically until Georgi's work, which started in 1934.

The occurrence of auricular fibrillation in three patients; notes regarding onset, nature and duration of manifestations.

Electro-cardiographic diagnosis, interpretation of and comparison with organic fibrillation.

The onset of heart-block immediately following a convulsion in another patient. Discussion of subsequent course and treatment.

Comment on the significance of these complications in relation to the safety of convulsive therapies.

Observations on blood-pressure in some of the above cases.

The insulin therapy of the psychoses as evolved by Sakel (1) was introduced to Three Counties Hospital 16 months ago. The total number of patients treated and under treatment is 74; 56 have had a full course of the treatment in addition to psychotherapy, and of these, 29 have been discharged and 4 will leave the hospital in the near future. A total number of 3,205 hypoglycæmic comas have been induced up to the present in 4,379 patient insulin days. Serious emergencies arose in only 6 comas. One patient had severe laryngeal spasm, another acute ódema of the lungs, and four delayed return to consciousness. No fatality occurred. Twenty-eight patients had 81 fits in the same number of comas. I shall outline briefly the circumstances which led up to the emergencies met with by myself and some published by other workers in this country, and give the treatment applied.

The popular conception of mental defect is that it is a common abnormality of a kind fairly easy to understand and to study, and for whose ætiology simple rules can be laid down. Textbooks on general medicine usually dismiss the subject in a few paragraphs, and even those devoted to diseases of the mind rarely find room for more than one short chapter on mental defect.

One difficulty which hinders the advance of psychiatry is that the facts of a mental disorder are not easy to describe and to record accurately. Many of the descriptive words used, such as “depression”, “confusion”, are taken from common speech and carry with them vague meanings. Out of sympathy with the sufferer, we tend to read our own emotions into the clinical picture. Moreover, because a disorder of thought and behaviour is a disorder of adaptation to living, the description of a mental disease involves not only the recording of the symptoms, but also a description of the circumstances and life-setting in which they occur. Another difficulty lies in the great variation in the clinical pictures of mental disorder. These vary so much that a diagnostic label such as affective psychosis or schizophrenia does not convey, and indeed is not intended to convey, an idea of a specific disease. These difficulties are somewhat more marked in the investigation of mental disorder in contrast to the investigation of mental defect. The statement that a patient is a Mongol or a cerebral diplegic conveys the idea of a fairly definite clinical syndrome, whereas a statement that a person suffers from schizophrenia calls up a much less clear mental picture. It seems that the only way out of this difficulty is to give a short statement of the clinical facts about each psychotic whom one discusses.

Since there are several excellent accounts of the technique of insulin therapy (1, 2, 3, etc.), and since our method is based largely on the recommendations of Sakel, we do not intend to describe this in detail, but to discuss such variations and points of interest as have developed at Hatton during the completion of treatment in 59 cases.

The term “schizophrenia” was first introduced by Bleuler (1) as descriptive of the dissociation and fragmentation of mental processes which he regarded as the chief characteristic of the condition. There is “a detachment from the world without, and a breaking up of normal psychological connections within. The personality is not integrated as in normal people; thinking emotion, and conduct are discrepant and morbid, yet there is no impairment of formal intelligence such as is found, for example, in organic dementia” (Mapother and Lewis (2)). To quote Bleuler (1), “even though we cannot as yet formulate a natural division within the disease, nevertheless schizophrenia does not appear to us as a disease in the narrower sense but as a disease group, about analogous with the group of the organic dementias, which are divided into paresis, senile forms, etc. One should therefore speak of schizophrenias in the plural. The disease at times runs a chronic course, at times in shifts; it may become stationary at any stage or may regress a certain distance, but probably does not permit of a complete restitutio ad integrum. It is characterized by a specific kind of alteration of thinking and feeling, and of the relations with the outer world that occur nowhere else”.

The outstanding successes claimed in the treatment of schizophrenia by two such apparently different forms of treatment as insulin and cardiazol lead to a comparison of their effects on body and mind. Amongst those who have studied the two methods individually are Angyal and Gyarfas (1937), and Georgi and Strauss (1937),

This preliminary survey of a group of schizophrenics at Friern Hospital was undertaken in order to find out whether such cases presented any electroencephalographic deviation from normal. In the event of positive results being obtained it was hoped that, in addition to further lines for research being indicated, some light might be thrown on the issues raised by Hoagland, Cameron and Rubin (1), (2), (3), and Lemere (4) regarding electro-encephalograms in treated and untreated psychotics.

It is well known that gross impairment of nutrition is a not infrequent finding in the newly-admitted psychotic patient. Some of these cases present a state of mental confusion which is directly attributable to a condition of semi-starvation brought about by personal neglect and refusal of food. Obvious clinical signs of malnutrition are present, such as anorexia, emaciation, coated tongue, constipation, and ketonuria. Rapid mental improvement frequently occurs as a result of a liberal diet and relief of gastro-intestinal stasis. But it is equally important to recognize the mild and less obvious forms of malnutrition.

Home-sickness springs from the conflict between family ties and herd or group feelings, and among immigrants, such as those Austrian and German domestic servants working in London, the nostalgic reaction may lead to certifiable mental disorder. The present study concerns forty cases of this kind who, between 1931 and 1937, came under my care at Friern Hospital.