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.

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.”

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 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.

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.”

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 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.

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.

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.

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.

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.

A small controlled series of cases of schizophrenia was treated with cardiazol at this hospital. A list of all those thought suitable for treatment was drawn up in order of date of admission and divided into two by selecting alternate cases. From the prognostic point of view there was little to choose between the two groups. The average duration of illness for all patients was six years. At the Berne-Munsingen Congress it was agreed that the remission rate falls rapidly with the duration of the illness, and that few cases of over four years' duration recovered with cardiazol treatment. This is also the opinion of others (1), (2), (3), (4), (5), (6), (7), (8), so no startling results were anticipated.

Since Hildebrandt (1926) described the convulsant effect of cardiazol injection, several studies have been carried out on the mechanism of such convulsions. Zung and Tremonti (1931) suggested a direct action on the respiratory centre when cardiazol is used as a stimulant; Kerr and Antaki (1937) found no effect on brain glycogen or phosphocreatine in cardiazol-induced convulsions; Hashimoto (1937) found differences in distribution of calcium and potassium ions in the central nervous system after cardiazol. Goodwin and Lloyd (1938) recorded a direct effect on brain potential changes as shown on oscillographic records. Leibel and Hall (1938) found a large (75 per cent.) diminution of cerebral blood-flow at the onset of cardiazol convulsions. Weigand (1938) found no effect on liver glycogen or vitamin A content, reducing power of suprarenal cortex or blood picture. Denyssen and Watterson (1938) and Watterson and Macdonald (1939) attribute the convulsions to action on the vasomotor centre and note the action of vasodilator drugs in inhibiting convulsions. Wortis (1938) quoted by Quastel (1939) found no effect on brain respiration.