In a previous article—” A Study of Mental Derangement in Africans “—the writer described primitive African culture, thinking and attitude to life, and the types of mental derangement seen in Kenya over a 5-year period, and endeavoured to explain the peculiarities in the incidence and nature of African mental derangement on the basis of cultural factors.

This paper is based on 66 child guidance cases. Children under 7 years were excluded because my Rorschach experience with them is too slight. All had psychotherapeutic treatment, mainly analytical, some had purely permissive play therapy, some combined this with analytical treatment. A few were treated indirectly through therapy of the parents. I have included some adults, parents of clinic cases, and one teacher.

It was noticed that, during the performance of the Kohs Blocks Test, a few patients would in some cases make the model correctly, but misoriented. Illustration i gives an example of such a phenomenon. The patient had to reproduce the design shown with four Kohs Blocks. His reproduction is shown. The pattern has been correctly reproduced, but has been misoriented by 45°. The pattern was never in fact misoriented to a greater extent than this.

The condition of physiological homeostasis results from the maintenance of a steady state for the functions of organs and the levels of different blood constituents, despite the constant variability of other factors from without and within tending to upset that steady state. Most organs of the body show variability and adjustment of their functions in the presence of stresses, but the brain cannot itself make such adjustments. Yet any change in the external or internal environment of the body affects the brain, and particularly the cortex, most severely. Homeostatic mechanisms function as defensive mechanisms, protecting the cortex of the brain from harmful alterations in the internal environment.

From Dr. Sakel's address there emerge two questions regarding the indications for insulin treatment in the psychoses which are worth discussing on this occasion:

(1) General indications for the treatment: Should every case of schizophrenia undergo insulin therapy, i.e., be admitted to a hospital as soon as the illness has been diagnosed ?

(2) Special indications and procedure: What is the role of convulsions in insulin therapy ? What proof is there of the presumed antagonism between coma and convulsion ? Are there any facts supporting the idea that insulin fixes the results of convulsion therapy ?

To-day I want to confine most of my remarks on the indications for shock therapy to problems concerned with the proper selection and handling of patients for E.C.T. I intend to make only passing reference to insulin.

In trying to contribute to this symposium one can either comment, in the light of one's own experience, on what the principal speakers say about indications in general, or one can pick out a special problem which requires clarification. I have chosen the latter course. I propose to report on some observations on the effect of “intensive E.C.T.” By this I mean the administration of two to four shocks on successive days over a period of a week or two, which aims at producing a confusional state with deep clouding of consciousness. It is the method that has been advocated in this country by Milligan. Cerletti devotes a section of his report to this method. According to him, it was Bini who first employed it. He noted that it resulted in a temporary and almost complete annihilation of mental life. Cerletti calls it annihilation therapy, l'anéantissement. Nobody who has carried out or witnessed this treatment will deny the aptness of the term. American writers have called it regressive E.C.T. Bini and Milligan have reported very satisfactory and lasting results in chronic neurotics who had failed to respond to other therapies.

It is time the term “shock therapy “was dropped. Its meaning is not clear, we constantly attempt to avoid shock to our patients, it is not always therapy and the term does not do us much good in the eyes of our colleagues or the public.

Our present state of knowledge concerning the changes brought about by shock therapy is such that the application of these forms of treatment is still largely empirical. This is due to the fact that we are not aware of the mode of action of these different modes of treatment and also because the classification of the various forms of mental disorders is still very unsatisfactory. This is particularly true when we are dealing with that heterogeneous group of mental illnesses lumped together as schizophrenia. Many cases of so-called schizophrenia will recover without and even in spite of shock therapy, and I very much doubt whether the concept schizophrenia has done anything to help us in choosing our cases. A diagnosis to have any value should give us (a) a clinical picture of the patient, (b) an indication of the course of the illness which would be helpful in giving a prognosis, and (c) some guidance as to the appropriate treatment for a particular patient. Most clinical psychiatrists will agree that the diagnostic label schizophrenia fails us in all these respects. I read with great interest in the booklet of the International Congress Dr. Meduna's article in which he divides schizophrenia into two groups (a) endogenous schizophrenia, and (b) symptomatic schizophrenia. He points out that shock therapy is of value only in cases of symptomatic schizophrenia, which is more or less identical with the confusional insanity and the exhaustion psychoses of the English Board of Control classification of mental diseases.

Shorvon and Sargant (1947) have given a full account of the history and development of the use of ether in relation to excitatory abreaction. They have shown how valuable its use can be to rid patients of emotional tension which has occurred as a result of some particular battle experience, such as being blown up, buried alive, torpedoed, etc. They propound various theories as to the mechanism of excitatory abreaction, and they give a full description of the technique they employed, illustrated by examples from the numerous cases with which they dealt.

The object of this study is to investigate the extent to which the MMPI reveals personality changes following prefrontal leucotomy, and how these compare with personality changes as shown in the results of intelligence testing.

The work of Cossa and Gastaut (1) and Gastaut (2) indicated the possibility of inducing a cerebral dysrhythmia, consisting of fast spikes or a fast spike followed by a slow wave, by a method of combined metrazol and photic stimulation. Modifying their technique and substituting hexazol (triazol) for metrazol O'Flanagan et al. (3) treated a series of cases with encouraging results, and in view of their findings it was decided to investigate the method further, and examine the effect of the induced dysrhythmia with special reference to psychiatric disorders.

This paper deals with the relation between crime and the psychoses complicating pellagra, and is based on a study of the cases of accused persons suspected of being insane, and admitted to the Abbasia Mental Hospital for mental examination and report during eight years from 1941 to 1948 inclusive. This examination was, in the great majority of the cases, carried out by the writer who, in virtue of his official position, is the expert psychiatrist to the Office of the Procureur-General.

The diagnosis, aetiology and treatment of schizophrenia are still outstanding among the most important, complicated and least understood problems of psychiatry.

Caspersson, Hyden and Hartelius, in a series of researches at the Caroline Institute, Stockholm, found that (a) nerve cells subjected to heavy stimulation become depleted of nucleoprotein; (b) nitrile compounds administered to the experimental animal hasten regeneration of this nucleoprotein; (c) biopsy specimens of the prefrontal cortex of psychotics removed at leucotomy show a reduction of cellular protein when compared with healthy subjects killed in accidents; (d) nitrile compounds have a beneficial stimulating action in psychotics and sometimes a permanent curative effect. The substance which they used, malononitrile, was toxic, liable to produce severe reactions and only usable with safety if, after the injection, the patient was kept under observation and given sodium thiosulphate at the first sign of trouble. Meyer and Meyer (1949) have adversely criticized their methods and conclusions.

From time to time accounts have appeared of recoveries and of deaths following the ingestion of large doses of aspirin. A further case is here reported.