Since its introduction to general medicine in 1922
insulin has been used as a therapeutic agent in an increasing
number of diseases and disorders.' In the treatment of the
psychoses it has played its part mainly in an attempt to
promote appetite and nutrition generally in cases of malnourishment.
Only rarely was insulin reported as having
any beneficial action on the psychosis itself. Since it
was regarded as essentially a physical adjuvant, any mental
improvement noted with its use was considered to be incidental.
In 1928 Manfred Sakel began treatment of certain mental
states with special interest in drug addiction. With this
beginning he developed a completely new form of treatment in
which insulin was administered in Nigh doses and in the absence
of carbohydrates. Since 1930 the technique has been evolved
with the object of deliberately producing a state of hypoglycaemia
which was allowed to deepen to the point of coma.
Hitherto this state had always been regarded as a dangerous and
undesirable complication, which should be prevented by the
administration of adequate carbohydrate. Sakel found, however,
that, if proper precautions were taken, these dangers had been
magnified, and discovered that a protracted state of coma had
a therapeutic value in combating mental diseases.
In Vienna, at the Pötzl Klinic, 46 cases had been
treated at that time and it was claimed that 70.7% had
responded with a full remission, and a further 17.3% with
a good social remission. In November 1936 Max Muller of
Munsingen reported on a series of 136 cases treated with the
Sakel method, and confirmed the good results, especially in
cases of less than six months duration.
Since then the so-called hypoglycaemic shock treatment
of schizophrenia has been used extensively in all parts of
the world. It was introduced into America by Glueck and
has since been reported upon by fortis, Moersch, Ross,
Katzenelbogen and others. Several hundreds of cases have
undergone treatment and opinions have been very conflicting,
both with regard to results obtained and t.o the method
employed. Though there are at present many reputable
advocates of the method, at the same time many authorities
have opposed it on practical as well as on theoretical grounds.
In order to clarify the situation to some extent, at
least in this country, Dr. Isabel Wilson was asked to make
an investigation of the matter and to deliver a report to
the Board of Control of England add Wales. This was in
February 196. In a careful and unbiased account Dr.
Wilson gave a description of her impressions of the treatment
it was actually carried out in Vienna under Dr. Sakel,
together with a detailed account of the technique, its
dangers and theoretical considerations. Certain recommendations
were added, including one that the treatment should
be started in a public mental hospital in this country.
Previously, and independent of the above report, Dr. Pullar
Strecker, who had studied the Sakel method in Vienna, was
invited to carry otit the treatment in a number of cases in
the Royal Edinburgh Hospital.
During 1937 a number of reports have been published in
this country dealing with the results of treatment. On the
whole favourable reports were ,iven by James, Larkin,
Hamilton and others. Whereas the British Medical Journal,
in a leading article, hailed the new form of treatment as an
advance, the Lancet opposed it on various grounds.
After a period of twelve months, in which eleven cases
were treated, it was decided to continue the method in this
hospital as the results were promising. The writer was
privileged to study the technique under the (guidance of
Dr. Strecker, and since July 1937 has carried out the
'treatment personally in a series of 25 cases.
The purpose of this essay is to outline the technique
and clinical observations of the treatment, and to deal with
the difficulties and dangers, theories of cure, and the
interpretation of results. A table is given indicating the
results, and six illustrative cases are added which are
considered to be representative.