It is proposed to consider first some little-noticed experimental facts about the accessory nasal sinuses, and some oft-repeated clinical observations, which are relevant.

The treatment of mental disorders by drastic methods coming as a “shock” to the patient was applied early in history all over the world (1). The severity of the procedure usually varies with the degree of civilization achieved. The earliest method was occipital branding. Water cures followed later: “The frantic person was placed with his back to the water without being permitted to know what was going to be done. He was knocked backwards into the water by a violent blow on the chest, when he was tumbled about in a most unmerciful manner until fatigue had subdued the rage.” Anglo-Saxon priests used a form of treatment described in Bald's Leechbook: “In case a man be a lunatic take the skin of a mereswine (porpoise), work it into a whip, swing the man herewith, soon he will be well. Amen.” (1).

Although Selter (1) appears to have described examples of this disease in 1903, it was not given its present name, nor was it generally recognized, until 1914, when Swift (2) in Australia described fourteen cases of a clinical disease entity and gave it the name of “erythroedema.”

Since then a number of other cases and series of cases have been described and much work has been done in investigating its possible pathology and aetiology.

Byfield (1920) (3), Parkes Weber, Thursfield and Patterson (1922) (4), Findlay and Stern (1929) (5), and Wylie and Stern (1931) (6) have contributed papers in the English language.

In 1923 Patterson and Greenfield (10) published a review of the disease and discussed in particular the pathology and causation of its polyneuritic aspect.

A description of the disease is to be found in most works on paediatrics, in particular those of Findlay (7) and Hutchinson (8), whilst Still (9) gives a series of 17 cases observed by him. A further description is given by Brain (12), whilst Rocaz (11) has published a monograph summarizing our knowledge of the disease. Reference to this and further literature will be made later in this paper as various points are discussed.

In the present investigation 15 cases of pink disease are considered. Of these 7 were obtained from the records of cases admitted to the Sheffield Children's Hospital in the two years 1931 and 1932. One was personally seen by the writer at St. Thomas's Hospital, London, in 1933, and 7 more have been personally investigated in the Sheffield Children's Hospital between October, 1933, and March 1, 1935. In addition many of the old cases have been seen and followed up in the Out-Patient Department by the writer. Some other investigations which bear upon the subject are also described.

The peculiar condition designated “fugue state,” of which the main symptom is compulsive wandering, has puzzled psychiatrists since it was first described. Nothing is known of the aetiology of this well-defined condition. Fugue states occur in epileptics, hysterics, and certain psychopaths. Bleuler has described their occurrence in schizophrenia, and they have been recorded in cases of general paralysis and of altered personality due to brain tumour. There are gradations between the typical fugue states and certain fugue-statelike conditions in psychopaths. Kraepelin recognized that it was impossible to distinguish between the states of compulsive wandering associated with various mental disorders. Janet tried to distinguish between hysterical and epileptic fugues by pointing out that short fugues are more likely to be epileptic than hysterical. Although to-day Kraepelin's view is generally accepted, the opinion is held that as a matter of course the mechanisms underlying an epileptic and a hysterical fugue are fundamentally different. Henderson and Gillespie, for instance, arguing against Kinnier Wilson, point out that in a hysterical fugue a search for personal emotional factors will reveal fully the cause of the fugue, while such factors usually play no part in epilepsy.

The intimate similarity of fugue states associated with different mental disorders suggests that there must be aetiological factors common to all. However, no attempt has been made hitherto to ascertain such factors. I have been engaged in investigations concerning this problem for more than eight years, and have published a preliminary report (Stengel, 1939) on some of the results.

Before entering into discussion of the problems involved, it is proposed to present reports on the individual cases observed, the number of which (25), considering the rarity of the condition, provides a large case material. The cases will be reported as briefly as possible, and special attention will be given only to the features which are important for the subject of this paper.

In not a few of the recorded cases of hyperostosis frontalis interna there has been observed some degree of cortical atrophy, chiefly affecting the frontal poles, and its occurrence raises the question of its possible relationship to the osseous change.

Three alternatives may be entertained: (1) Brain atrophy is caused by the encroachment and pressure of the hyperostotic area on the surface of the brain; (2) brain atrophy is primary, the shrinkage of the frontal convolutions in some way exciting a compensatory bony overgrowth ; (3) the two processes, osseous and neural, are entirely independent of each other.

Spratling (1), writing in 1904, was the first to draw attention to the possible association of epilepsy with food sensitization. Previous to this observers had been impressed by the fall in fit incidence which occasionally accompanied intercurrent diseases, notably typhoid and tuberculosis. Hamilton (2), some years later, confirmed these observations in respect of intercurrent typhoid. It was not, however, till 1919 that Pagniez and Lieutaud (3) detailed the first authentic instances of epilepsy definitely ascribable to a specific food substance. These were two cases of sensitivity towards chocolate. The authors demonstrated that withdrawal of chocolate led to a cessation of seizures, and that these returned when it was re-introduced into the dietary.