The part played by sex hormones in the genesis and pathology of mental disorders is still the subject of striking differences of opinion among psychiatrists.

The way in which schizophrenics react to physical illness and injury is a problem worthy of study, especially at the present time when schizophrenia is being so widely treated by methods which bring about profound changes of the physical state. Although schizophrenics, recent and chronic, are very susceptible to physical illness and form a considerable part of the sick population of the average mental hospital, this question has not attracted a great measure of attention. A survey of the schizophrenic population of a mental hospital suggests that there is an apparent lack of specific psychotic reactions to physical illness, so that it would seem as if schizophrenics react to physical illness either in a normal way or more commonly with indifference. It is true that certain paranoid patients include complaints of physical disturbances in their systems of delusions, but as a rule, even in these cases, there is no specific reaction to physical illness, which like other experiences enters into the world of imagination in which the patient exists.

During recent years so much has been written about convulsive therapy that it would seem rash to burden still further the very extensive literature on this subject. Nevertheless, in spite of the admirable work that has been done, it cannot be said that the implications of convulsive treatment are fully understood, nor that the fullest possible use has been made of this treatment for research into the pathophysiology of epilepsy. Furthermore, the recent introduction by Cerletti and Bini (1) of a method of treatment with electrically produced epileptic fits has increased still further the scope of research. I have had at my disposal case material provided by the treatment of various forms of mental disorder with cardiazol for more than two years, and with the electrical method in collaboration with Mr. Grey Walter for about six months. This has enabled me to conduct certain investigations of a sort that have received little or no attention hitherto, and to make observations covering various aspects of the physiology and psychopathology of induced epileptic states.

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.

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.

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.

Epilepsy is as old as history. To the ancients it was a sacred disease, each convulsion signifying a visitation of its victim by one of the gods. Hippocrates first seriously attributed epilepsy to material causes, but the light of scientific approach which he momentarily kindled was soon extinguished, and for centuries the mysteries of epilepsy remained shrouded in a cloud of mysticism and religious cult, and if treatment was administered at all it usually consisted of incantations and spirit-exorcising rituals. In the modern era of medicine scientific battle has been joined with this disease in common with all others, and since the epileptic, like most other sufferers, is liable to an exacerbation of his disease in times of mental and physical stress, the present human warfare cannot but render more important than ever successes in the therapeutic field against epilepsy.

In no other branch of medicine have doctors appeared so nihilistic or so defeatist as in the domain of psychiatry. It seems to me questionable whether this is due to the disparity in the therapeutic results between psychiatry on the one hand and general medicine on the other. In general medicine it is frequently forgotten that the really specific remedies at our disposal are so few that they can be counted on the fingers of one hand. If, on the other hand, we remember that as late as the time of the French Revolution mental patients were kept in chains, and that to-day in modern hospitals we see impressive results with such specific treatments as malarial therapy, then it must be admitted that the psychiatrist is not the only nihilist; but that this also applies to representatives of other branches of general medicine.

This case is a perfect example of that rare form of mental disorder, acute systematized hallucinosis (sensory insanity) described by Bianchi, as characterized by “hallucinations of several senses, repeated in a uniform manner, determining a range of false thoughts rapidly systematized, acute and curable.”

Many papers have already been published on the technique of insulin therapy for the psychoses (Müller, 1936; Sakel, 1937 and 1938; Frostig, 1937; Küppers, 1937; Braunmühl, 1938, and others). Nevertheless, some of the details of the method still offer problems to the careful therapist who wishes to avoid impairing his therapeutic effects by excessive caution, but is unwilling to incur unpredictable risks. While investigating this therapy during 1938 at the Maudsley Hospital, we endeavoured to evolve a technique which was both effective and safe, and which could be individualized to each patient without thereby losing its precision. In the following paper we offer suggestions concerning some of the technical details that have appeared to us important in achieving these ends. As far as possible we have omitted points on which previous papers have given adequately clear and consistent instructions.

The anti-convulsant value of sodium diphenyl hydantoinate (S.D.H.), marketed in America as Dilantin and in England as Epanutin, as found by Putnam and Merritt and introduced by them in the treatment of epilepsy has been amply confirmed by all subsequent reports, as it is by this one. Its clinical application, however, will, it is thought, be modified by reason of its toxic nature becoming more generally known.

Recent hysteria is not a disease. Its manifestations represent the pathological exaggeration of a normal protective mechanism. By this mechanism otherwise well-adjusted individuals are enabled to gain time when a sudden reverse of fortune or an overwhelmingly difficult decision presents itself. Its purpose is to ease the blow and thus to prevent that paralysis of effective response which may result from the too sudden realization of the full implication of a situation.