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 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.

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 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.

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.

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.

(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.

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).

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.

A search was made for statistical studies of the remission rate in cases of schizophrenia which had received no specialized treatment such as hypo-glycæmia. The search was confined to the period since 1918, as the period influenced by broader and more hopeful views of the nature and prognosis of “dementia præcox”. It was also confined to studies in which the remitted cases had been followed up for some time after discharge to avoid errors due to early relapses. The results of all these statistical follow-upstudies aie given in Table I. The various writers have classed their results in somewhat different ways, and it has been necessary, in constructing the Table, to fit all the results under standard headings.

The title of this paper may seem over-ambitious in the scope which it predicts, for it is obvious that much more space would be required to cover all the ground. It should be made clear that we are concerned here mainly with the administrative side of child guidance, which has of late years become a vital concern to the members of this Association. During the past few years there has been growing in the minds of all those interested in the promotion and preservation of mental health a belief that a co-ordination of existing mental health services should be carried out. At present these services are too sporadic and are uneven both in distribution and efficiency. London and the great cities are rich in mental health services of all kinds, but in the counties and smaller towns there are but meagre provisions. This is well illustrated by the voluntary societies concerned with the treatment and prevention of mental illness. There is, for example, the Home and School Council, which works on the principle that a better relation between parents and teachers constitutes a creative force in mental health, and further provides a unique channel through which mental health knowledge can be brought before the general public without the risks attached to indiscriminate propaganda. Another society, at the other end of the scale, is the Mental After-Care Association, which attempts to bridge the difficult gap which patients experience between leaving a mental hospital and taking up life in the ordinary world again. Yet another society is the National Council of Mental Hygiene, whose broad aims are to educate the public in mental health matters, to promote closer association between psychiatry and general medicine, to further the early treatment of mental disorders, etc. The Central Association for Mental Welfare was, at its inception, mainly interested in the problems of mental defect, but now has a wide range of activities, such as the organization of training courses for medical officers, teachers and mental welfare workers, co-ordinating local activities in many areas and making provision for cases which fall outside the scope of smaller authorities, and undertaking public activities relating to propaganda and the promotion of legislation. In a more limited field the Child Guidance Council attempts to encourage the provision of skilled treatment for children showing behaviour disturbances or early symptoms of nervous and mental disorder and, in general, to further the practice of child guidance. In addition to those societies which are directly concerned with mental health, there are many others, such as the British Social Hygiene Council, the National Association of Probation Officers, the R.S.P.C.A., the Howard League, the National Institute of Industrial Psychology, whose work lie on the borders of this field. It is obvious that there is a great deal of overlapping, and the need for co-ordination is being attained through a temporary reconstruction committee under the chairmanship of Lord Feversham, which will shortly publish a report.

Although considerable attention has been devoted during the past years to the problems of the influence of heredity on mental deficiency, no final conclusions have yet been reached. It appears well established at the present time, first, that in a large percentage of cases, variously estimated at from 40 to 80%, mental deficiency is significantly determined by genetic mechanisms, and second, that recessive genes seem to play a considerable role in such mechanisms (Lokay, 1929; Brugger, 1930a; Smith, 1930; Luxemburg, 1931; Juda, 1934; Kreyenberg, 1935).

It is not known to what extent convulsions induced experimentally by various agencies are related pathogenetically to epileptic fits. There are, however, facts which suggest that the induced convulsions have, in their several mechanisms, points in common with one another and with epilepsy. Thus, caffeine and absinthe both cause convulsions in cats; when sub-convulsant doses of both are administered together convulsion ensues, suggesting that the two drugs operate on the same mechanism (Notkin and Pike, 1931). Insulin hypoglycæmia occasionally causes convulsions; it has been shown that during hypoglycæmia in man there is a lower fit-threshold to cardiazol (Georgi and Strauss, 1938), and in cats to thujone (Keith, 1935). The elicitation of convulsions by electrical stimulation of the cortex is facilitated by camphor monobromide, absinthe (Muskens, 1928), and cardiazol (Santha, 1939) on the one hand, and in epileptics as opposed to non-epileptics, on the other (Pen-field, 1936). Hydration has been shown to play a part in the precipitation of convulsions due to hypoglycæmia (Drabkin and Ravdin, 1937), thujone (Keith, 1935), and epilepsy (Fay, 1929; MacQuarrie, 1929).