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Psychiatric Drugs Explained

SEVENTH EDITION

David Healy, MD FRCPsych

Professor of Psychiatry, Department of Family Medicine, McMaster
University, Hamilton, Ontario, Canada
Table of Contents

Title page

Copyright

Preface

Introduction

Consumers and Compliance

Individual End-Points

Pharmacopsychology

1. The person on treatment

Chapter contents

Introduction

Christmas tree light bulb test

Section 1: Management of the Psychoses

2. The antipsychotics

Chapter contents

Introduction

History of the antipsychotics

Are antipsychotics antischizophrenic?

How antipsychotics work

A ‘who cares’ feeling

Antipsychotics and positive symptoms of psychosis

Antipsychotics and negative schizophrenia

Clozapine and second-generation antipsychotics

Antipsychotic doses

Flexible therapy

For how long should treatment continue?

Depot antipsychotics

Antiemetics

Antipsychotics and psychotherapy

Significant interactions

Special conditions

3. Antipsychotic side effects and their management

 Chapter contents

Introduction

Dopamine system effects and side effects

Non-dopamine side effects

Management of side effects

References

Section 2: Management of Depression

4. The antidepressants

Chapter contents

Introduction

History

Depression

Do antidepressants work?

What do Antidepressants do?

Antidepressants: first choice or last resort?

Starting antidepressants

Stopping antidepressants

Antidepressants and children

5. Side effects of antidepressants

Chapter contents

Introduction

The ambiguous side effects of antidepressants

Effects special to the MAOIs

References

Section 3: Management of Bipolar Disorders

6. Management of acute bipolar disorder

Chapter contents

Introduction

Lithium for mania

Antipsychotics for mania

Anticonvulsants for mania

Carbamazepine

Sodium valproate

Lamotrigine, gabapentin and oxcarbazepine

Topiramate and vigabatrin

Acetazolamide
 Electroconvulsive therapy (ECT)

Benzodiazepines

Do antidepressants cause mania?

Bipolar-mania

7. Mood-stabilisers

Chapter contents

History of mood-stabilisation

Lithium as a mood-stabiliser

The anticonvulsant mood-stabilisers

Carbamazepine and oxcarbazepine

Sodium and semi-sodium valproate

Lamotrigine

Gabapentin and pregabalin

Topiramate and levetiracetam

Antipsychotics as mood-stabilisers

Cocktail treatment

Coda

References
Section 4: Psychotropic Drugs For Children

8. Stimulants and drugs for children

Chapter contents

The history of the stimulants

The emergence of ADHD

Stimulant treatment for ADHD

Non-stimulant drug treatments of ADHD

Non-drug treatments of ADHD

Other uses of stimulants

Psychotropic drugs and children: general principles

The use of antidepressants for children

The use of antipsychotics for children

References

Section 5: Management of Anxiety

9. The anxiety disorders

Chapter contents

Drugs used in anxiety

Forms of anxiety
 The notion of an anxiolytic

10. Benzodiazepine and gabapentinoid anxiolytics

Chapter contents

Introduction

Mechanism of action of the benzodiazepines

Classes of benzodiazepines

Clinical uses for benzodiazepines

Benzodiazepine dependence and withdrawal

Gabapentinoids

11. Serotonin and anxiolysis

Chapter contents

Introduction

Serotonergic receptors and drugs

Serotonin and anxiolysis

12. Beta-blockers and anxiety

Chapter contents

Introduction

Performance-related anxiety
 Generalised anxiety disorder (GAD)

Panic attacks: a puzzle?

Tremor

Akathisia and restlessness

Prazosin and post-traumatic stress disorder (PTSD)

References

Section 6: Management of Sleep Disorders and Insomnia

13. Sleep disorders and insomnia

Chapter contents

Introduction

The sleep disorders

Insomnia

14. Non-pharmacological management of insomnia

Chapter contents

Caffeine

Environmental factors

Relaxation

Body awareness
 Stimulus-control treatments

Routines

Paradoxical intention

Forward planning

Use of mantras and yogic breathing exercises

Medication

15. Hypnotics

Chapter contents

Introduction

Common hypnotics

16. Sedatives

Chapter contents

Melatonin and its analogues

Chloral compounds

Barbiturates and related compounds

Chlormethiazole

Sedative antidepressants and antipsychotics

Antihistamines

References
Section 7: Management of Cognitive Impairment

17. Cognitive enhancement and the dementias

Chapter contents

Introduction

The dementias

18. Cognitive enhancement and neuroprotection

Chapter contents

Introduction

Second-generation cholinomimetics

Cholinomimetics in other therapeutic areas

Memantine (EVISTA)

Management of multi-infarct dementia

Management of subcortical dementias

Neuroprotection

Cognitive enhancement and the politics of diagnosis

Smart drugs

References

Section 8: Management of Sexual Difficulties

19. The range of sexual difficulties

Chapter contents

Introduction

Women and men

Male potency

Ejaculation and orgasm

Libido

Sexual responses in women

Sexual orientation, objects and practices

20. Effects of drugs on aspects of sexual functioning

Chapter contents

Drug effects on sexual function: males (See Appendix 20.1)

Ejaculatory and orgasmic effects

Drug effects on sexual function: females (See Appendix 20.2)

Aphrodisiacs

Yohimbine, trazodone and cyproheptadine

Intrapenile treatments

Phosphodiesterase inhibitors

Anti-aphrodisiacs
 Post-SSRI sexual dysfunction (PSSD)

Persistent genital arousal disorder (PGAD)

Appendix 20.1

References

Section 9: Management of Dependence and Withdrawal

21. Dependence and withdrawal

Chapter contents

Introduction

Rebound symptoms

Withdrawal syndromes

Brain physiology

Tolerance

Withdrawal syndrome

22. Dependence and craving

Chapter contents

Introduction

Craving

Behavioural sensitisation
 Appetites

Pharmacological management of appetites

Psychological factors in substance abuse

Disinhibition

23. Dependence and protracted withdrawal

Chapter contents

Historical perspective

Antipsychotic and antidepressant dependence

Stress syndromes

Protracted withdrawal or legacy effects?

References

Section 10: Consent, Abuse And Liability

24. Consent

Chapter contents

Introduction

Voluntary consent

Information and comprehension

Clinical trials and legal jeopardy

 Compliance

Prescribing

25. Pharmacological abuse

Chapter contents

The problem

The dynamics of abuse

Prescription ‘rights’

The Right not to be disabled by treatment

References

Section 11: The Marketing Of Tranquillity

26. The ethical industry

Chapter contents

Introduction

The magic bullet

The interface between ethics and markets

Consequences

27. Evidence-biased care

Chapter contents
 Access to data

The origin of randomised trials

The placebo effect

Rcts and efficacy

What's wrong with RCTs?

Pharmagnosia

Rcts are risky

28. Marketing and risk

Chapter contents

The marketing of depression

The marketing of bipolar disorder

The marketing of female sexual dysfunction

Rating scale mongering

Risk management

The new marketing

29. From healthcare to pharmageddon

Chapter contents

Perceptions of progress in mental health

Healthcare versus health products ltd

 Pharmageddon

References

Index
Copyright
© 2023, Elsevier Limited. All rights reserved.
Second edition © Times Mirror International Publishers Limited 1997
Third edition © Harcourt Publishers Limited 2002
Fourth edition © 2005, Elsevier Limited. All rights reserved.
Fifth edition © 2009, Elsevier Limited. All rights reserved.
Sixth edition © 2016, Elsevier Limited, All rights reserved.

The right of David Healy to be identified as author of this work has

been asserted by him in accordance with the Copyright, Designs and
Patents Act 1988.

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Notices
Practitioners and researchers must always rely on their own
experience and knowledge in evaluating and using any information,
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Preface
In 1993 when the first edition of this book was written evidence-based
medicine (EBM) was just emerging, and prescribing by nurses in the
UK and pharmacists or psychologists elsewhere was just starting to be
talked about.
The biggest need in 1993 for a book like this seemed to be the need
to assert the primacy of the language that people used in trying to
describe what was happening to them and that those working in
health care used when witnessing what was happening to people on
treatment over a new biological language about lowered serotonin
levels and dopamine receptor blockade.
EBM initially seemed like an ally in this effort as it was explicitly
about combining the best evidence with patient and clinical values,
and it put much more weight on clinical trials than on biology. EBM
has however become as big a threat to the ability of two people in a
clinical situation to interact in a human way as the biomythologies
ever were.
We now have both a language of chemical imbalances and a
language of controlled trials and epidemiological data and guidelines
based on these trials and the system puts more weight on both of
these than on the merits of looking at and listening to what a person
on a treatment is saying about what the treatment is doing to them.
EBM is about average effects rather than what is happening to the
person talking to me. And the pharmaceutical industry has been
masterful at arguing that if controlled trials haven't shown that
something is happening then it's not happening, not quite saying
patients need to be told their complaints are all in their mind.
From 1993, this book has been about what might be called data-
based medicine (DBM). When most people hear EBM they assume
they are dealing with DBM when in fact they aren't. The first and key
message of this book is that the person on treatment is the data. Being
scientific means that we and the person or people on treatment need
in a collaborative way to attempt to map the experience the person on
treatment is having and perhaps after that attempt to explain it.
Dismissing what is happening as coming from their mental illness is
not scientific.
Many medical prescribers tell patients that they, the doctors, are
scientists and unless the patient has had 10 years' training in medicine
their views don't count. But one of the cardinal rules of science is that
a scientist is supposed to be keeping an eye out for the observations
that don't fit into the current world view. She is supposed to be
looking out for the Black Swans – the examples that don't fit with the
observation that all swans are white. We need to encourage anyone on
treatment and anyone working with someone on treatment to form
Black Swan Clubs that challenge those who deny the value of
experiences – however they are explained.
This will not be an easy task. While the original purpose of EBM
was to empower the patient, it has effectively been co-opted by
pharmaceutical companies and we now have a world in which it is
more and more difficult for anyone to believe the evidence of their
own eyes or what they are being told by someone on treatment.
The main argument put forward against listening to the person on
treatment is that we want objective knowledge and what patients
have to say is often too subjective. That begs the question as to where
objectivity comes from.
This book is committed to the idea that for the most part people
when they report something are going to be correct and health care
staff when they see something are likely to be correct also. Not
always, but mostly. It was women and their hair stylists who noticed
the effects of oral contraceptives on hair – not doctors.
If the person reporting what happens or the clinician reporting
what they see invites others with a different point of view (a different
bias) to consider the issues and they also come to the same conclusion
that the drug seems to have triggered this particular problem then this
is even more likely to be correct and is in this sense more objective. If
several people taking drugs report the same thing and several
different people not on the drug – even pharmaceutical company
employees – having looked at all the issues in these people's case
agree that the most likely explanation for what is happening is that
treatment has triggered it then it becomes ever more likely that this is
the case. This drug can cause this effect. It may not usually cause it
and we may not know how it causes it in some people and not others,
but it can cause it.
This is where objectivity comes from. Science is a group process. It
doesn't depend on experts or people being free of bias. It's about
replicating something in front of us. The ‘biased’ person can help by
pointing to details we may not have taken into account. The expert
can help but not when it comes to novel effects when by definition no-
one is an expert. The expert can be more helpful later in accounting
for the effects.
Compared with the opportunities to investigate all angles of
individual cases and to weigh different factors, controlled trials are
simply mechanical exercises that depend on the observations of
clinicians and patients in the first instance. Rating scales are no
substitute for the ability to talk in detail to a person. Trials that
depend on scales and adhere to rigid protocols are blunt instruments
that are not designed to look at the fine grain of behaviour. Objectivity
does not come from a mechanical exercise like this. To err is human, to
really foul things up needs a controlled trial.
I am not contrasting the Art of Medicine here with the Science
found in trials. The Science of Medicine lies in being able to explore
experiences with an individual patient and in attempting to account
for their experience. Trials, and in particular those linked to industry,
are perhaps better seen as the Artifice of Medicine.
Fifty years ago a mother presenting to a doctor or hospital with a
newborn infant saying that something was wrong was not believed,
especially if the tests showed nothing wrong. Now all the books say
believe the mother even if the tests show nothing wrong.
 When things go wrong, someone taking a psychotropic drug today
is in a similar position to mothers 50 years ago. The challenge to us all
is to change this. The challenge to non-medical prescribers will be to
do better than doctors.
Introduction
Chapter contents

Consumers and compliance xii

Individual end-points xii
Pharmacopsychology xiii

There are typically four parties to the act of taking any psychotropic
drug: the taker, those who live with them, the prescriber and the
company that produces and markets the drug. All four are bound up
by the history of our attitudes to psychological problems, to
psychotropic drug taking and to the processes of industrialisation
taking place both within the pharmaceutical industry and within
medicine. All four are also shaped by changing attitudes in society at
large, one of which involves an increasing awareness of the rights of
individuals, included in which is a right to information about
treatments we may be given.
These forces have conspired in recent years to bring about the
production of handbooks about drugs that cover their mode of action,
their potential benefits and their possible side effects. However, such
handbooks consist mostly of lists of drugs with bold statements of
reputed modes of action and comprehensive lists of side effects. These
give little flavour of how these drugs may interfere with individual
functioning or impinge on individual well-being.
One of the aims of this book, in contrast to others, is to produce a
text that makes the issues live. There is a lot of detail about the history
of different drugs. On the question of what the various drugs do, both
current thinking and current confusions are outlined. Too much
certainty is, I believe, the enemy of both progress and science.
Apparent academic certainty also tends to invalidate the perceptions
of a drug taker, who is the person best placed to ensure their own
safety and contribute to the further development of
psychopharmacology in the process.
I also include an attempt to assess the influence of the
pharmaceutical industry on the perceptions of both clinicians and
patients.
Rather than simply give a list of benefits and side effects, I attempt
to give a fuller description of what the experience of the side effects
may be like and how these impinge on normal living. To try to put
some flesh on the bare bones of a list of side effects means that I have
compromised between being comprehensive and being significant.
Readers should be aware that this book does not include every known
side effect. It does not include precise figures as to the frequency of
each side effect. It does not include all known interactions with other
compounds. What it does include are the reactions and interactions
that occur regularly, and the book attempts to give some feel for how
important these are.
What emerges, nevertheless, is a list of side effects that, in many
respects, is rather fearsome – to add to a set of motives on the part of
both prescribers and the pharmaceutical industry that are often venal.
Many of my colleagues wonder whether taking this course of action is
advisable. I have a number of reasons for thinking it is.
Consumers and Compliance
The final arbiter of whether psychotropic medication is useful or not is
the taker. The taking of any psychiatric drug involves a trade-off
between the benefits the drug confers and the risks it entails. Until
recently, prescribers have been accustomed to making this trade-off
for those for whom they prescribe. In general medicine, where
respiratory or cardiac function is concerned, this is often the only
possible course of action. But where psychotropic drugs are
concerned, this is neither the only option nor the best option.
In psychiatry, prescribers often moan about non-compliance with
the regimens they prescribe. In the absence of any systematic work on
why the takers of the drugs we prescribe are non-compliant, the
vacuum tends to be filled with a vague view that patient recalcitrance
amounts almost to a culpable or moral failing. It seems that we rarely
stop to appreciate that anyone worth their salt is going to think
seriously about continuing treatments with medications that may
obliterate their sex life, make them suicidal or generally make them
feel worse than they were before they began treatment. There have
always been prescribers sensitive to issues like this, but there have
also been far too many of us who, when faced with complaints about
the medications we prescribe, have tended almost reflexively to
increase the dose of what has been prescribed or to add some antidote
to counteract the side effects of the first prescription, rather than to
listen carefully to the substance of the complaint.
We are taking a tremendous burden on ourselves in proceeding this
way. But, more importantly, in doing so we neglect the assistance of a
group of potential mental health workers whose services come for free
– our patients. Fully informing the client of the nature of the
compounds, of their potential benefits and equally of their limitations
and side effects, and of the available alternatives, at the very least has
the merit of deflecting legal criticism. More importantly, however, it
has the potential benefit of enlisting the takers of psychotropic drugs
in the enterprise of handling their own condition, regarding which
they may often be uniquely sensitive.
Individual End-Points
The reason for this last claim is that, where drugs are concerned, one
person's cure may be another's poison. My first awareness of this
came from a very simple practical exercise, many years ago in medical
school. A group of 10 of us were given a beta-blocker to take. This
should slow the heart rate, and it did – for nine of us – but one of the
group had a marked increase in heart rate. This suggested that she
was ‘wired up’ differently to the rest of us.
A few years later the lesson was brought home again in a study in
which clonidine was given to some colleagues. Clonidine lowers the
concentration of noradrenaline in the bloodstream, and in the group
as a whole it clearly did so, but in 20% of those investigated it
produced an increase.
In the central nervous system, where there is a multiplicity of
receptors for each drug to act on, and where all of us have different
proportions of each of these, the likelihood of a uniform response to
any one drug is rather low. A diversity of responses, rather than
uniformity, should be expected. Nevertheless, in practice prescribers
tend to operate as though uniform responses were the norm. This
inflexibility can be fatal. Where psychological problems are concerned,
healthcare staff traditionally have had the escape route of blaming
patients killing themselves – because the drugs we prescribe make
them feel worse – on the neurosis or irrationality that brought them
for treatment in the first instance. This avenue of escape – blaming the
patient – is one we should be reluctant to adopt.
Another random document with
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 CHAPTER VI
“Illustrious Mr. Pinocchio,” began Globicephalous, “if you do not
wish to stay with me, I can walk by myself. We can meet to-night.”
“No, Globicephalous, do not leave me,” begged the
brave son of Mr. Geppetto, the carpenter. The idea of
being alone with all those fish gave him the shivers.
“But you may be ashamed,” began Globicephalous.
“Please forget that. Now listen to me. You are a
servant, and you can’t have studied much. Still you
may know this: Mr. Tursio does not want me to call him
a fish. What is he, if not a fish?”
“Do you think Mr. Tursio would dare tell a lie to such an important
personage as you are?” said Globicephalous, who was having some
fun all by himself. “Neither Mr. Tursio nor Master Marsovino should
be called fish. Nor I either, for that matter.”
“What are you, then? Birds? You have about their shape, and you
live in the water. I know that in the sea there are only fish.”
“But you are mistaken. To many animals that live in the sea you
cannot give the name fish,” continued Globicephalous. “Fish have a
flat body, wedge-shaped fore and aft, as the sailors say, so that they
may move rapidly both forward and backward. They are each
provided with fins and a tail. These fins and the tail enable the fish to
swim about in the water. Some fish have only a few fins, others have
more. Then the fish has no lungs. It breathes in the water by means
of gills. These are the chief characteristics of fish. But in the sea are
many animals which do not possess them.”
“Please explain yourself,” said Pinocchio, who had understood little.
“Very well. Listen. There are the cetaceans, to which belong the
whales, the narwhals, and the dolphins; the amphibians, to which
belong the frogs and the seals; the mollusks, which is what the little
animals that live in shells are called; the crustaceans, which is the
correct name for the lobsters, crayfishes, and crabs; and the
zoöphytes, among which are the corals, sponges, and the many
varieties of polyps. All these, you must know, are not fish.”
“What hard names!” said Pinocchio, to whose wooden head these
big names meant but little. “What are you, then?”
“My masters and I are all cetaceans. We cannot stay in the water all
the time. We must often come to the surface, because we need air.
We have no scales like fishes nor fur like seals, but we have a
smooth thick skin under which is a layer of fat.”
“Thank you. But why, if you and your masters are all dolphins, are
you so unlike?”
“For the simple reason that there are different kinds of dolphins, just
as on the earth there are different kinds of dogs. As you have
noticed, we are of different shapes and sizes. We have different
names, too. I am a globiceps, my master is a tursian, and the young
master is a marsouin.”
“Who would ever think the sea is full of so
many wonderful things!”
“Still you have not seen anything of what
there is to see! On all sides there are new
things. Look at this,” continued
Globicephalous, picking up a shell and
showing it to Pinocchio.
“Well, what is it? A lobster with a flower
riding on its back?”
“Almost that. It is a small crustacean called
the hermit crab.”
“Hermit?”
“Yes. It is called that because it shuts itself up in a shell as a hermit
does in his cell. This crab’s cell is the empty shell of a mollusk. And
do you know why it shuts itself up?”
“No. Please tell me.”
“Because the back part of its body has no hard covering. So the
crab, to protect itself, uses the shell as a house and thus goes about
safely.”
“He must be a clever little fellow to think of that! But this flower on
the top—is that a part of the crab’s body?”
“That is not a flower; it is an animal.”
“An animal! But don’t you see that it has leaves all around?”
“Yes, and in fact it has the name of a flower. It is
called a sea anemone. But if you look closely you
will see the little leaves, as you called them, moving
busily.”
“It is really true!”
“They are tiny arms which the anemone uses to get
its food. Throw a piece of meat near them, and you
will see them gather themselves together. In a second the meat will
disappear into the body of the animal.”
“It seems hardly possible,” said Pinocchio again and again, as he
watched the anemone closely.
“This anemone,” continued Globicephalous, “is a great friend of the
hermit crab. Whenever you find one of these crabs you will find an
anemone on its back. When the crab grows and has to move to a
larger shell, do you think, my illustrious Mr. Pinocchio, that he
abandons his tenant? Never! The anemone has no legs, so the crab
takes her very carefully in his claws and carries her to his new
home.”
“It sounds like a fairy story!” Pinocchio exclaimed, wonderstruck.
“Still these things are real, Your Honor, and are seen here every
day.”
Pinocchio, who had liked the idea of being called “Illustrious” was
delighted to hear himself addressed as “Your Honor.”
“So this servant thinks me a great man,” he thought proudly to
himself. He strutted round as if the whole world belonged to him.
While he was walking with his head in the air and his hands in his
pockets, he struck a round, flat object with his foot. Picking it up, he
looked it over carefully.
“Does Your Honor know what that is?” the cetacean asked him
mockingly.
“Of course. It is the bellows my cook lost a few weeks ago, and this,”
he continued, picking up another object, “is the crumb brush our
maid lost last Sunday and looked all over the house for. I wonder
how they came to be here?”
Globicephalous turned a somersault, the better to hide his laughing
face.
Pinocchio, thinking that the dolphin believed all his tales, continued
his proud walk.
 “Globicephalous turned a Somersault, the better to hide
his Laughing Face.”

Lying on top of a rock not far off was a transparent object of beautiful
colors. It was closely woven like a net work, and looked like a fan.
Pinocchio, having started on the road of story-telling, did not feel like
turning back.
“Just see how careless that maid was,” he began again. “Last
summer I gave her this beautiful lace fan, and now see where I find
it! Good care she takes of my gifts!”
Globicephalous continued his somersaults.
“Look again! These are surely the plants that were stolen from my
conservatories last winter,—”
Globicephalous had had too much. He interrupted Pinocchio with:
“And this, if it weren’t so small, might be used to whip boys who sell
tinsel for gold.”
Globicephalous was holding up a small object, which really looked
like a whip.
“What do you mean?” haughtily asked Pinocchio. “Do you dare to
doubt my word?”
“I don’t doubt it. I know there is not a word of truth in anything you
have said.”
“How do you know? Isn’t it possible for me to have a palace and
servants?”
“You might have, but you haven’t.”
“Who told you so?”
“I know it without being told.”
“How?”
“Listen. Do you want to know what these two things are,—the
bellows and the brush?”
“The bellows is a horseshoe crab. If you turn it over you will see it
has ten legs like a lobster. The brush is a sea fan. The little plants,
which were stolen from your conservatories, are simply coral polyps.
All except the crab are zoöphytes.”
“Now do you see, my great Mr. Pinocchio, why I cannot very well
believe all your tales?”
Pinocchio was simply breathless. “Zoöphyte! Zoöphyte!” he
exclaimed. “What does that big word mean?”
“Oh,” replied Globicephalous, with a learned air. “That word means
an animal that looks like a plant.”
“By the way, I remember you asked Mr. Tursio for a feather to put in
your cap. Here it is.” And Globicephalous gave the marionette a
long, delicate, feathery object of a bright yellow color.
“And what is this?”
“Another beautiful zoöphyte. And to finish the trimming of your cap
you might use this five-pointed starfish.”
“What? Is this a fish, also? Surely you are mistaken!”
“Oh, no, Mr. Pinocchio, I am perfectly sure that I am not mistaken.
The starfish is just as much an animal as the coral is.”
“It was a long time before people learned that coral is made by tiny
living animals. But now everybody knows that there are hundreds of
the little coral animals living and working together on the same
branch.”
“These little animals grow and multiply very quickly. In a short time
they even make mountains under the sea.”
“You know how to tell fanciful tales better than I, Globicephalous.”
“But my tales happen to be true ones, though they do seem fanciful.
That mountain you see there is made by coral polyps. If you should
climb to the top of it, you would find yourself on an island.”
“Very well. I’ll try it. I might find my father.”
“Yes, or you might meet some one, and ask whether he has been
seen.”
“Ask! Do people live on islands in the middle of the sea? What are
you talking about?”
“Let me explain. After the islands are made, little by little they are
covered with earth. Then plants begin to appear from seed blown by
the wind or dropped by the birds. Then man may come. Why not, my
boy?”
“I have enough to think over just now. Good-by for a time.”
“Good-by. I will stay here. Do not lose your way.”
Without answering, Pinocchio began to climb. He was as agile as a
monkey, and was soon far up.
“I do hope I shall not lose my way,” he thought. “What a joke it would
be to be lost at the bottom of the sea!”
 CHAPTER VII
Pinocchio climbed and climbed. The poor boy was
getting very tired. Still he wanted to be sure the
dolphin was right. So he went on bravely.
At last the water began to grow lighter, and even his
wooden head could understand that he must be
near the surface.
“It must be the light of the sun which I see,” he
thought. “On, my brave Pinocchio, and the top will
soon be reached. Hurrah! Here I am!”
With a bound he was—yes, the dolphin was right—on the shore of a
real island.
Shaking the water out of his clothes, he looked around. Those little
beings, the corals, had certainly worked wonders.
“Shaking the Water out of his Clothes, he looked Around.”

The island was rather bare of trees and grass, but there was a cave
near the shore which soon attracted Pinocchio’s attention. He went
into it. It was not very large, but one could easily see that a man had
been there.
“People must certainly be living here. From now on I shall have to
believe Globicephalous,” thought the marionette.
When he came out, he walked around and started to explore the
island. He came to a small pond. In it lived not only frogs, but also
thousands of other tiny animals.
Pinocchio stopped to look at the water. It looked as green as grass.
He certainly would have had another shock if some one had told him
that the tiny animals that lived in it made it green. Yet that was really
the case.
These animals are not visible to the naked eye. Still they are present
in such great numbers that water sometimes looks green, sometimes
red, and at other times even black, on account of them and their
color.
This was not what interested Pinocchio most, however. He saw other
animals swimming around very quickly. Some were very tiny, very
long, and had no legs.
Others, a little larger, had two legs. Others had four legs, and still
larger ones had a short bit of a tail.
Perhaps you have guessed, children, what Pinocchio was looking at.
The small black animals were tadpoles.
When he was tired of looking at the pond, Pinocchio turned toward
the sea. He thought he might see his father, but he was
disappointed. Suddenly he gave a great shout of surprise.
And no wonder! As if by magic a fleet of tiny boats had appeared on
the surface of the water. They were no larger than an egg shell. Nor
was this all. From each little skiff rose two little rose-colored sails,
and each tiny boat put out three pairs of oars as long as knitting
needles.
“I wonder where the little boats came from,” cried Pinocchio. “Surely
this must be fairyland.”
“No, my boy, you are not in fairyland,” he heard a voice behind him
saying. “Those are simply shells.”
Turning quickly, Pinocchio saw a little fat man standing before him,
looking him over.
“Shells!” repeated the marionette, too surprised to think of anything
else to say.

“Turning quickly, Pinocchio saw a Little Fat Man standing

before Him.”

“Yes, shells.”
“And are they also animals?” Pinocchio had asked this question so
many times that it came from him unconsciously.
“Yes, they are. They are small mollusks of strange form. When they
come to the surface of the sea, they turn the opening of their shells
upwards. Then they raise their sails, put out their oars, and float
away. They are called argonauts. Aren’t they pretty?”
“How beautiful they are! But see! They are disappearing!”
“Yes, because clouds are gathering. It looks as if a storm were
coming up, and these little animals don’t like storms. So they are
taking refuge under the water.”
“By the way,” began Pinocchio, “will you please tell me whether or
not you have met a little old man looking for his son?”
“No, I have not.”
“Well, then, good-by. It is getting late, and I must meet some friends
of mine.”
But the little man did not wish him to go, so he held him by the arm.
“Listen here, my little man, where did you come from?”
“From the sea.”
“Really?”
“Yes, I am taking a trip under the sea with three dolphin friends of
mine.”
“Under the sea! How can you live there?”
“One of the dolphins made me an antibian.”
“You mean amphibian, my boy. What a wonderful experience you
must be having.”
“Yes, but please let me go now. I must meet my friends, or they will
go without me.”
 “You Won’t?”

“In a minute. But first tell me where you got that beautiful shell you
have on your head.”
“The dolphin Tursio gave it to me. He called it a long name, and said
it was very rare.”
“I know it. Will you give it to me?”
“No, I like it too much myself.”
“You won’t? Well, then, I shall have to take it,” and the man quickly
put out a hand for it.
But Pinocchio was quicker still. He gave a great jump, but oh! poor
fellow, he did not know how near the edge of the rock he was. Before
he could realize it, he fell headfirst into the water.
 CHAPTER VIII
Down—down—Pinocchio sank, straight to the
bottom of the sea.
And here we must remember that we are to think of
Pinocchio as a real boy of flesh and blood. Only the
shell was of wood. Otherwise he would have floated
away on the surface of the water.
When he finally touched sand he felt half dead. It
was not a very pleasant experience to fall through
so much water.
After a while, feeling better, he got up and looked around. He was in
a strange place, a place he had never seen before. Of
Globicephalous there was no sign.
The poor boy was frightened almost to death. He thought a trick had
been played upon him. But if he had had his wits about him, he
would not have been so puzzled.
Poor thoughtless marionette! He did not remember how he had
walked around in his explorations. He had fallen into the sea on the
eastern side of the island, and Globicephalous was waiting for him
on the southern side. But Pinocchio’s wooden mind knew nothing of
east or south.
“Oh! poor me,” he could not help crying, “and now what shall I do? I
cannot climb this steep rock. If I remain here, I shall be eaten in no
time by some of these fish I see swimming around.”
In fact, immense tunnies were passing near him. Enormous rays,
looking like giant fans, dashed by. Over him glided horrible
uranoscopes, or stargazers.
These fish, like the halibut, have both eyes on the tops of their
heads, and so can only see above them. Luckily, Pinocchio was
 under them, otherwise—
“I am afraid I am not very safe here,”
observed Pinocchio, whose knees were
beginning to feel weak. “If these fish
notice me, I shall disappear. I do wish I
could find dear old Globicephalous.”
Thoroughly frightened, he started to run
madly along. Of course he ran in the
wrong direction.
“I wonder what this is,” he grumbled. He
had stepped on something large and
hard.
He pushed the thick seaweeds aside. In
their midst he found a large turtle. For a
wonder Pinocchio knew what it was.
“How fortunate you are!” sighed the
marionette. “At least you have a house.
In that armor of yours you are safe from
anybody.”
But such did not seem to be the case. The harmless reptile was lying
quietly in the weeds trying to sleep. But even though Pinocchio was
in such a plight as to be lost in the sea, still the love of mischief had
not left him. Taking the poor animal by its hind legs he turned it over
on its back.
The poor thing struggled and tried to right itself, but all in vain. When
a turtle is on its back, it has to stay there.
This is so well known that when fishermen catch them they turn them
over, sure of finding them in the same position even a day later.
Seeing another shell near by, Pinocchio was about to treat it in the
same manner. But as it felt very light he examined it closely. It was
empty. The animal had probably been dead a long time, and the
shell alone was left. It was almost a yard long.
 As he was looking at it, he chanced to
turn his head upward. Horrors! What did
he see? An enormous animal was about
to throw itself upon him!
No one had ever told Pinocchio what
this fish was. Still, even he could easily
guess its name. Its strange shape is so
much like that of a large hammer that it
is unmistakable. It was the terrible
hammer that Tursio had spoken about.
“I am lost,” breathed Pinocchio, closing
his eyes and throwing himself flat
amongst the seaweed.
Who could have blamed the poor boy for
being frightened? He had seen that
large gray mass coming nearer and
nearer with wide-open mouth. He had
seen the large black and gold eyes at
the ends of the head, gleaming brightly
with thinking of the coming feast. Poor
fellow!
But just as he was imagining himself in
the shark’s mouth Pinocchio realized
that the minutes were passing and that
he was still alive.
“He may have changed his mind about
committing a marionetticide,” he
reflected with eyes still closed.
Time passed, and thinking that the shark
had not courage enough to attack him,
Pinocchio had the courage to—open his
eyes. He could hardly believe what he
saw. The shark was moving away. Still, he could see that the fish
was going because he had to, not because he wanted to. Looking
more carefully then, he saw a strange sight. Three small fish were
sticking to the sides of the hammerhead, and were pulling him away.
Our hero had never seen such strange-looking animals as those
three fishes. They were small and narrow, and on their heads each
had a large flat object, which looked just like a dish.
If the dolphins had been there, they would have told Pinocchio that
these dark-colored fish are called remora. With the flat disk they can
attach themselves to other fish. Sometimes they let themselves be
carried. At other times, when they feel in the mood for mischief, they
pull others along wherever they wish. This is what happened to the
shark.
“Those fish certainly saved my life,” thought Pinocchio. “But I hope
the shark won’t do to them what he wanted to do to me.”
Feeling in need of a place of safety, he tried to hide himself in a large
hole in a rock. But he had hardly put one foot in, when he felt his
shoe being pulled off by a large claw. Two eyes at the ends of two
long sticks glared ferociously at him. It was a large lobster. Pinocchio
had disturbed Mr. Lobster while he was looking for dinner, and so
had been punished. Happily for Pinocchio the lobster was satisfied
with the shoe! If the claw had taken hold of the foot also, it might
even have gone through the wood, and then, poor Pinocchio!
In disturbing the lobster our hero must certainly have offended its
whole family. Before he could realize it, the sand before him was full
of horrible crustaceans. Frightened out of his wits, he could just look
and wonder when they would stop coming. From every hole in the
rock they came, little ones, big ones, flat ones, round ones.
And ready to fight they certainly were! With claws in the air and eyes
roving madly they approached. Very carefully they looked the boy
over. A lobster or a crab never begins to fight unless he knows what
he has to deal with.
And still they kept coming! Wherever Pinocchio turned, there was a
horrible creature. To the right the large mouth of a common lobster
threatened him. To the left an ugly spiny lobster shook his claws at
him. Behind and before him the sand was covered with them, large
 green crabs, common crabs, porcelain
crabs, common lobster, spider crabs,
glass crabs, tiny fiddlers, and others.
As if these were not enough, out of a
hole came a crab larger than any of the
others. He was rapidly coming nearer,
but before long one of his claws was
grasped by one lobster, the other by
another. Without the least movement to
fight, the crab just pulled off his claws,
and quickly went back to his hole.
Pinocchio was thunderstruck. How could
the crab do this so calmly? For the
simple reason that the crab preferred
losing his claws to being killed and
eaten up. In a few months he would
grow another set of claws as good as
those he had lost. Yes, a crab can do
that, children. Think of it!
“Oh, dear me!” thought Pinocchio, who was getting rather nervous by
this time. “What is going to become of me? If only I had a shell as
has a turtle I could hide away and be safe.”
“Oh! what a splendid idea!” he suddenly burst out. “Why didn’t I think
of it before? I shall have a shell to hide in!”
And without another word he slipped into the shell he had been
looking at. In a moment nothing could be seen of him, not even his
nose.
The crustaceans did not understand with what kind of a being they
had to deal. So after examining the shell all over, they slowly
disappeared into their holes.
With a great sigh of relief Pinocchio dared to stick his head out of the
shell. Seeing his shoe lying on the ground, he quickly put his foot in
it. It was not very pleasant to walk on the sand without a shoe.