a. Introduction.

Neurological symptoms in hypoglycaemia seem bewildering and difficult to analyse because of their variety, covering, as one author puts it, the entire range of neurological and psychological manifestations. There are great differences between individual cases, each following a certain pattern of symptoms. Even this pattern may vary from day to day in the time and mode of onset and in the progression of symptoms.

During the first two decades of this century important advances were made in our knowledge of syphilis. Wassermann in 1904 introduced the serological reaction which bears his name; Schaudinn and Hoffmann discovered the spirochaete in 1905; Plaut in 1908 extended the application of the Wassermann test to the cerebro-spinal fluid; Ehrlich in 1909 synthesized “606”; Noguchi in 1913 demonstrated spirochaetes in the brains of general paralytics, and Wagner-Jauregg in 1918 inaugurated malaria therapy. During the second two decades no outstanding discoveries have been made, but there has been in these last twenty years a large amount of verification and elaboration; more sensitive serological tests have been devised, new chemo-therapeutic drugs have been manufactured, the histology of parenchymatous neurosyphilis has been more fully studied, and many methods of pyretotherapy have been tried. A review of the vast literature which has been published soon reveals the fact, however, that there are still numerous outstanding problems awaiting solution, many of which were already being discussed 20 and 30 years ago.

As syphilis is a contagious disease it is a matter for surprise that so few investigations have been made into the conjugal histories of patients suffering film general paralysis of the insane.

Until quite recent years the figures of O. Fischer (1913) have largely been quoted when the incidence of conjugal neurosyphilis has been brought into question. Among the husbands of 86 female paralytics he found 8 cases of conjugal neurosyphilis. More recent inquiries have been made by Moore, the Solomons and Kemp, and their results have been summarized by Moore (1933).

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 haemorespiratory system is subject to disease like any other tissue of the body. Degenerative changes of large arteries are known to have occurred thousands of years ago, and atherosclerosis is to be found throughout the world irrespective of race or geographical distribution. The first recorded observations of disease of the cerebral vessels appeared in the year 1700 (1). Perivascular softenings were noted in 1814 (2); a book on disease of the brain with clinical associations was published in 1836 (3). Atheroma was studied in 1844 (4), and periarteritis of the cerebral vessels in 1868 (5) and 1887 (6). Changes in the vessel walls and perivascular cells were noted in 1863 (7), and white cells and emboli seen in cerebral vessels in 1882 (8).

It was generally expected, before the actualities of war arrived, that not the least effect of it would be a shattering of the mental health of the civil population.

War on great cities was to be a particular application of what the war lords called the war of nerves. Propaganda, threats and their ultimate fulfilment with bombs and fire were to be the weapons of the future. With this in mind, arrangements were made to receive psychiatric casualties on the assumption that the civil population, untrained and unprofessional, would suffer in at least as large numbers as soldiers in the last war.

The Rorschach method is valuable in the study of personality and claims have been made for its application to clinical diagnosis. Clinicians would welcome any method which would help to distinguish “psychoneurotic” from “organic” disease. There is a tendency, however, to demand from a new and unfamiliar method a complete diagnosis, rather than that the technique should provide standardized information which can be used towards a diagnosis by the clinician along with other methods. Psychologists using the Rorschach method have played into this expectation to some extent and have sought to present sets of signs and types of Rorschach records which could be considered as suggesting certain definite diagnoses. This paper is concerned with the study in a wide range of patients of some of the signs obtainable by the Rorschach technique in an effort to determine what degree of specificity can be attributed to them, and what likelihood of success and failure is attached to their use.

Fatigue is one of the commonest complaints a physician encounters, so common indeed that it gives little guidance for the diagnostic approach. Besides, fatigue is a normal phenomenon; so why and when does it become a symptom, in other words an indicator of illness ? Fatigue is a conspicuous symptom in effort syndrome cases, and the close association between effort, or rather incapacity for effort, and fatigue suggested an approach to the effort syndrome problem from the angle of fatigue.

Fatigue, as used in psychomatic medicine, has both a subjective and an objective meaning. According to the prevalent interest in the somatic side the objective aspect has been studied more than the subjective in medicine; even the psychologist tends to interest himself in the objective results of fatigue rather than in the psychological phenomenon as such.

The aetiology and pathology, as well as the clinical characteristics of those diseases of the nervous system in which the myelin sheaths and the axis cylinders are unsystematically affected, but the other elements of the nervous tissue spared, are as yet incompletely understood. Of these diseases, the group in which the changes of the nervous system are associated with anaemia and other dyscrasias of the haemopoietic system, generally classified as subacute combined degeneration of the spinal cord, is the most clearly defined. However, even in this group cases occur in which the characteristic degeneration of the spinal cord is not accompanied by gross pathological changes in the blood. There is still, therefore, much research required before these atypical cases can be brought into line with the general pathological conceptions of the subacute combined degeneration. Furthermore, the existence and character of pathological changes in the brain and other parts of the nervous system of cases with subacute combined degeneration, apart from the spinal cord, remain to be investigated more fully. The case which we have to report has various special features, the study of which should contribute in some degree to the elucidation of these complex problems. In this case, which presented the typical picture of a subacute combined degeneration without blood changes, there was an extensive affection of the brain and the peripheral nervous system.

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).

Many different opinions are held about the value of metrazol (cardiazol) shock treatment. Large quantities of statistics are available which compare the recovery rates of treated and untreated patients (Bateman and Michael, 1940). Studies of the objective changes in treated cases have been less frequent. The present communication describes some experimental work directed towards elucidating clinical changes in patients treated with metrazol at the Ontario Hospital, London. Three psycho-physiological tests were employed: reaction time, tapping rate and strength of grip were measured. Psycho-physiological measurements, formerly used extensively (Kraepelin, 1920), have, for some years, been discredited as means for obtaining information about abnormal mental states (Stoddart, 1926). They retain their popularity as aids to the measurement of the effects of drugs such as alcohol and benzedrine (Thornton, Holck and Smith, 1939), and they have been used for the rating of general mental efficiency in aviators (Stamm, 1920), or as tests for loss of function due to anoxia (McFarland and Barach, 1937). Every test carries with it an element of experimental error and, in watching for improved performance attributable to a drug's effect, special care has to be taken to ascertain what improvement, if any, could be attributed to chance factors, to practice or to familiarity. Thus, the additional study of repeated performances of normal adults and control patients in the same test situation is necessary. It has, in the past, been amply demonstrated that the performances of psychotic patients on psychomotor tests are less efficient than those of normal people (Dorcas and Schaffer, 1934). Reaction time is lengthened, tapping rate slowed and strength of grip diminished. Moreover, an abnormal degree of variability in the response is common (Whipple, 1925) because the efficiency of some patients changes capriciously during a test. Other patients are found to show even less variety than normals (Shakow and Huston, 1936).

Few patients in British mental hospitals are given a standardized mental test. Such tests may not be indispensable, but properly interpreted they tend to a precision otherwise lacking in clinical observation. Many psychiatrists rely on the answers to haphazard questions on general knowledge, simple arithmetic and so on. These not only have an indefinite significance, but may flatter to deceive.

The readjustment of the emotional problems of childhood which show themselves in behaviour disorders and nervousness is a most important part of any mental health service. This involves not only the relief of the immediate situation, but also prevention of more serious symptoms which may appear in adult life.

It is now being realized that the war-time evacuation of children is increasing the urgency for dealing with these problems on a broader basis. A recent editorial in the British Medical Journal (1941) stressed the strain that wartime imposes upon children by the break-up of normal family life and the consequent loss of security. It emphasized that these problems are seen mainly in the evacuation areas and stated, “There is in this situation a very real danger that the seeds of neurosis will be sown in an increasing number of children.”

Increased welfare and social work can do much to improve the situation, but many children need further treatment. There is an urgent need for more centres where adequate treatment can be obtained for selected cases. This paper indicates the methods by which children can be treated satisfactorily in an ordinary psychotherapeutic out-patient department when a fully established Child Guidance Clinic is not available in the district.

Each child is given an intelligence test, and mental defectives are not accepted for treatment by these methods. Detailed history from the parents is supplemented by visits of the psychiatric social worker to the home and to the school. In mild cases readjustment of unsuitable environmental conditions will effect improvement, but in more severe cases other measures will also be necessary.

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.

In the estimation of intellectual level the adherents of the Binet-Simon scales still claim for it a predominant position (1). This type of code is empirically constructed, and relies on obtaining small samples of cognitive behaviour of widely different kinds (2). There is, however, another system of testing, diametrically opposed in principle to the Binet plan. This, which is sometimes styled the factorial principle, acknowledges its theoretical dependence on the well-known conceptions on Intelligence of Prof. Spearman (3). The factorial tests are specifically designed to measure the statistically determined “general factor” only. Both methods have their advocates and the theoretical advantages and disadvantages have been hotly debated. The theoretical aspect is not of concern in the present study however. This was undertaken to discover whether the Cattell series of scales—perhaps the most important factorial test series (4)—could be used with advantage to replace or supplement the Binet scales, e.g. the widely used Terman-Merrill Revision—in the clinical examination of adult defectives, who are mainly of high grade. The scales have been compared, in other words, from the point of view of clinical practice, rather than of scientific theory.

The psychiatrist, the neurologist and the cardiologist all meet with patients who complain of their liability to a certain type of “attack” characterized by alteration of their apprehension of reality, varying degrees of subjective distress, and bodily symptoms of autonomic dysfunction, amongst which the cardiac components are given the most prominence. These attacks are often referred to as “acute anxiety attacks” by the psychiatrist and “vaso-vagal attacks” by the neurologist and the cardiologist, and vary considerably in their features and severity. The neurologist sees the most punched out clinical pattern, and in consequence it was the neurologist, Sir William Gowers, who first drew attention to them in his book, The Borderland of Epilepsy.

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.

Sodium amytal (sodium-isoamylethylbarbituric acid) has been used in psychiatry for several purposes; its uses in producing lucid intervals in catatonia are acknowledged (Bleckwenn). Broder employed it for the first time in continuous narcosis; and later, in combination with caffeine, he used it for therapeutic purposes in the treatment of psychoses; Harris, Horowitz and Milch discovered its prognostic value in insulin and cardiazol therapy, and Hermann, its effects in clearing psychogenic amnesias. It gradually lost its interest from the research point of view because sodium amytal (S.A.) appeared to be similar in results to ordinary hypnosis, but in the course of our own observations we found definite differences between the two.

The psychiatrist is brought into contact with the patient who has received a blow on the head some time after the event in the majority of cases. His task is in many instances to be shared with the neurological surgeon. The Army psychiatrist is called upon to see such a large number of such cases that the following somewhat exoteric account is offered as covering some of the major considerations involved.

A blow to the head may result simply in stunning, in which case the patient thereafter remembers, if vaguely, the essentials of his behaviour and experience, or the alteration of consciousness may be more severe and for some recognizable interval he may subsequently possess a true amnesia, in which case we speak of concussion.

The degree of concussion clearly comprehends a wide range of disturbance of function which may almost immediately be fatal.

Thirdly, the patient may be killed outright.

Functionally considered, therefore, there are three degrees of effect from head injury : stunning, concussion, and death. Structurally we have no real parallelism of observed pathology, since it is only cases of severe concussion which characteristically come to autopsy. Consequently nothing is known for certain concerning the pathology of concussion. Cerebral contusion is therefore clearly inadmissible as a synonym, although its existence may be presumed in severe cases.

As regards the after-effects of head injury it is clear that the disturbance of function may be psychogenic or physiogenic, or a mixture of the two, and in discussing the physiogenic results there are two main clinical methods of approach. In the first our interest is focused on syndrome production, and in the second we are more concerned with individual function. Clinical orientation, however, as in all psychiatry, can only be achieved by the former.