The senile psychoses are in regard to their origin an unsolved problem. Much valid work has been done in the field of anatomy and histology in approaching this problem, but as the mental diseases of old age cannot be separated from the growing old of body and mind generally, this problem is more or less a biological one. The borderline between old age and senile dementia is not a sharp one. In brains of old people without clinical symptoms of dementia there have been found histological changes, such as are usually found in cases of senile dementia. This makes it probable that the extent of degeneration of brain cells alone is not decisive for the appearance of senile psychoses. The finding of the characteristic plaques in the brain of senile psychoses may give evidence of the extent of the process and the severity of clinical symptoms, but it does not tell us anything about their nature and origin. Whether a constitutional factor is decisive or whether the histological changes are a reaction to an unknown noxa is undecided. Heredity may have its share too.

The purpose of this paper is to attempt to correlate results obtained from liver tests with the nosological demarcation of psychoses. The knowledge of the outstanding importance of the liver in general metabolism (it provides 12% of the turnover of energy of the body) and of its relation to some organic diseases of brain has been the subject of numerous investigations. Expectation of finding the starting-point of any disease in the liver, however, will at first not be placed too high if one recollects that every gland is only part of a system. Even where the symptoms of liver or other glandular impairment are characteristic for limited groups of psychoses deductions must be guarded, and the discovery of an unequivocal bodily symptom does not mean elucidation of the aetiology of a mental 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.

This paper represents a preliminary attempt to investigate some aspects of the influence exercised by the endocrine glands on the cerebral blood supply at various stages of development.

Much has been written about the possible somatic modifications that cardiazol, triazol and other convulsive agents bring about, and many investigations directed towards the elucidation of physical changes have been attempted. Such work in the materialist tradition of medicine is, no doubt, valuable. It would be unfortunate if it were to obscure other considerations.

This subject has a moderately extensive literature and examples have been recorded by various authors for some years. Most of the cases, however, have been the subjects of some pathological lesion, either congenital or acquired. Perhaps the earliest authentic case is the one originally described by Rosinius Lentilius in 1698, and quoted by Critchley, of a female, presumably young, epileptic sinistrad. The sex is not as important as the other factors, but it is a pity that there is no reference to the intellectual capacity. It is, if nothing else, a pointer to the usual type of case studied. In the adults, hemiplegics seem to have proved the most fruitful source for those collecting examples of this phenomenon, although a full list of causes is well known.

The management and treatment of patients suffering from catatonia are constantly presenting a problem for mental hospital staffs, particularly in modern times, when more emphasis is laid on treatment than on custodial care.

The problem of making people suffering from catatonia into useful members of the hospital community seemed, from the very beginning, to be bound to fail, as long as the difficulty of inducing them to active and voluntary movements was not overcome.

A new and extremely interesting conception of schizophrenia is opened up by the observation of the sign of dys-symbole made by Skottowe. He has defined this sign as “a state of mind which manifests itself by the inability of the patient to formulate his conceptual thoughts upon personal topics or to discriminate the gradations of his emotions in language which is intelligible to others, notwithstanding that he may be in a state of clear consciousness, while he still retains word-utilizing ability at the level of perceptual thinking, and so is not aphasic in terms of sensori-motor neurology”.

In the course of routine clinical work with excited patients I found that a dose of 3 drm. of paraldehyde with 3 gr. of dial (2 tablets) often produced a long and sound sleep where other powerful narcotics were relatively ineffective. It therefore seemed worth while to try the combination for prolonged narcosis. At the outset it was attractive in that it was cheap, was given by mouth, and that both drugs had a good reputation for efficiency and safety. Paraldehyde has also the special advantage of not being a cardiac depressant (Edmonds and Gunn, 1936; Sollman, 1937). Both drugs have been used before for prolonged narcosis, but not in this combination, and usually in much higher doses. [For references, see reviews of Palmer (1937) and Gillespie (1939).]

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.

Meduna and Rohny (1939) have recently commented on the rise of sugar and lactic acid in the blood of schizophrenic patients following therapeutic cardiazol fits. Insulin causes a lowering of the blood sugar, but later the resting level becomes higher than before treatment. Hence they suggest that the alteration of carbohydrate metabolism in the direction of diabetes may be the common mechanism underlying both forms of treatment, and this hypothesis is supported by Nyiro's observation (quoted by Meduna and Rohny) that diabetes is rare amongst patients with schizophrenia.

The Terman vocabulary test is probably used in mental hospitals more often than any other single test for measuring intelligence. The 1937 Stanford Binet Vocabulary List contains only 45 words selected from the original hundred. There is therefore a temptation to use it in place of the old one on account of its brevity. But this may cause serious errors.

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.”

In a previous paper published in the Journal for July, 1938, the vitamin C content of the urine of 50 psychotic patients was estimated. Although it was found that the urine content was on the low side, no definite conclusion could be reached as to whether there was any correlation between the form of mental disorder and the deficiency of vitamin C. Since that time the urines of another 256 patients have been examined, which, together with the original 50, make a total of 306.

Mr. W. T. O—, aged 48. Admitted to Han well (now St. Bernard's) Hospital on 15. iv. 1904.

The patient was admitted from Wormwood Scrubs prison, and there is no available information regarding his condition before his admission to hospital. At this time it was stated that he was confused and unable to give any accurate information about himself. He was garrulous and his conversation was largely incoherent. There are no details of his physical condition on admission. In 1908 he is described as being elated and garrulous. He expressed many delusions of grandeur, stating, for instance, that he was owed large sums of money and possessed his own private carriages, etc. He was rather childish and his memory was impaired. His physical condition was stated to be “much improved “and he was able to be up and about. Even so he showed definite and obvious physical signs of general paralysis (unequal pupils, reacting only sluggishly to light, tremor of lips, etc.).

Numerous workers (Plaut, 1935; Altaman, 1937; Monouni, 1937) have reported that the blood and spinal fluid ascorbic acid levels are low in the aged. No adequate explanation of this fact has been given. Wortis (1938) has suggested that, since oral administration increases the ascorbic acid level of the spinal fluid in the aged as in the young, defective absorption probably does not play a significant part. He believes that the lower values in older persons may be due to increased intensity of metabolic processes concerned with the elaboration of ascorbic acid. Friedman, in discussing this contribution, advanced the suggestion that in older persons there may be less need for ascorbic acid because metabolism is slowed.

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.