During the routine investigation of the blood of patients at Tooting Bec Hospital it soon became obvious that a considerable number showed either a positive Wassermann reaction and a positive Meinicke or only a positive Meinicke.

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.

This paper is concerned with the occurrence in three cases of a major psychosis of more or less circumscribed and apparently psychogenic episodes similar to those described by Ganser (1897), and which form a characteristic syndrome, since called after him. Two of the cases here described were endogenous depressions, the third was a schizophrenia. All three showed depersonalization.

Therapeutic convulsions were introduced by Meduna in 1934, but it was not until the latter part of 1938, after many thousands of fits had been induced all over the world, that spinal injuries were first recorded (Wespi, 1938; Stalker, 1938). The reason for this is not far to seek; it lies in the fact that these injuries are for the most part symptomless, and consequently to be found only by means of routine radiographic examinations. In 1939 alarming reports of the high incidence of compression fractures following induced convulsions were published, and the possibility of subsequent permanent disability led in many hospitals to the abolition of a very useful form of treatment.

The conditions of warfare in the present war have so far differed markedly from those in the 1914-1918 war. Up to date (September, 1940) the incidence of psychoses and neuroses appears to be comparatively small. One cannot however foretell what may occur later, and perhaps the following observations on psychoses in officers in the last war may be of some value. They were the subject of a paper I read to the East Sussex Medico-Chirurgical Society in 1920. I have made practically no alterations in the text.

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.

Skin sensitivity had been mentioned and demonstrated in isolated instances over a long period of years before Schloss in 1912 extended and described its usage and established it as a definite means of detecting hypersensitiveness. Since then it has been universally recognized as a most useful adjunct to the study of the aetiological problems of allergy. At first it seemed that a miraculous means had been found of explaining both the cause of and the reason for the recurrence of certain common disorders of obscure aetiology in widely separated organs. It promised to show how totally different symptoms could be attributed to a common agent. The fact that the skin was sensitive but that the only clinical evidence of disease appeared, say, in the lungs gave the impression that all organs of the body must be in a like state of sensitivity. This has since been widely disputed and denied and on this subject Alexander (1936) states that such an assumption, at least from the clinical standpoint, is a fallacy. Man, he believes, may exhibit general hypersensitivity if a sufficiently large dose of protein be experimentally introduced.

If, then, hypersensitiveness is localized in certain tissues, it follows that the skin may or may not be sensitive in any given case and at any given time. In other words, because the ingestion of a specific food leads to colic or urticaria, it does not necessarily follow that the skin will give a positive reaction to an extract of that food in all cases or at all times. Indeed, a positive reaction may not occur at any time. This limitation of skin testing is now accepted; but nevertheless, allowing for the fact that only 50-60 per cent. of allergics (and that is not an over-generous estimate) give positive results, it still remains a very valuable diagnostic aid.

The following 50 cases are presented as representative of psychical illness among the Services in Singapore. The majority are R.A.F. personnel, though a few have been included from Navy and Army sources. There are also in this series six cases of such illness among wives of Service personnel. These last have been included, because nervous illness necessitating repatriation and occurring in wives presents the same quantitative inconvenience to the authorities as such illness in the troops themselves, for in these cases the husband is usually repatriated as escort.

Convulsion therapy in some form is now in common use in the majority of mental hospitals. A method of inducing convulsions by electrical stimulation of the brain was introduced into this country in 1939 (1, 2, 3, 4, 5, 6).

This method commended itself readily because of the ease of operation, the freedom from special disadvantages inseparable from the use of a blood-borne drug, and the greater accuracy of dosage possible. Several papers describing this method and some early results have already appeared (7, 8, 9, 10).

This communication is a summary of convulsion therapy in a series of 40 cases admitted for psychoneuroses occurring in war-time. It comments on similarities and differences observed during treatment as compared with the convulsion treatment of psychotics, and discusses the psycho-dynamics of convulsion therapy. It is assumed that the reader is acquainted with the elements of convulsive treatment and the various phenomena which may result therefrom.

On December 8, 1939, 35 patients, neurotics and psychotics, met in “Sunnyside House” and formed a social club. The chair at the meeting was taken by a patient. We had previously met this patient with a few others, and explained to them the aim we had in view in proposing that they formed a club. Later this aim was expressed in the following paragraph which is taken from an article written for the first magazine of the Club :

“We find there are two main problems common to many who come to a modern mental hospital—the problem of ‘occupation’ and the problem of 'social relationship,’ that is, the relationship between the ‘I’ and the ‘ you.’ It was with the importance of the latter problem in mind that we suggested the establishment of a social club… . The satisfaction of successful co-operation is one of the surest foundations for happiness and inner security. Many of us here are lonely souls who have walled ourselves off to some extent from the society of our fellows. For one reason or another we have avoided the social impact and retreated into solitude and isolation. We have thus deprived ourselves of the possibility of co-operative activity and of the sense of security and fulfilment that this can bring. The Sunny Side Club will enable us to take the first few steps in the direction of fuller social co-operation by giving us the opportunity of working together on its various committees or of joining in its activities.”

Since Sakel's introduction of hypoglycaemia into the therapy of psychoses, discrepancies between the level of the patient's blood sugar and the severity of disturbance of consciousness have frequently been noted. The blood sugar decreases in a relatively steep curve within the first and second hour after the injection of insulin; but only after it has remained on a low level—differing from case to case—for a considerable time does the patient go into coma.

It seems useful to define the clinical signs of coma if it is intended to correlate it with laboratory findings. It is a state of unconsciousness in which the patient cannot be roused by sensory stimuli; in coma such stimuli do not provoke local and purposeful, but global movements only, if any. Once in coma the patient remains so, independently of the blood-sugar level, which can rise and fall within a certain range without visible change in the clinical picture; it may even rise to a level at which the patient was awake or could be easily wakened before he went into coma. Subcutaneous or intravenous injections of adrenalin in coma produce a rise in blood sugar without clinical effect. On the other hand, the flooding of the blood stream with sugar by nasal tube feed of a concentrated sugar solution or by intravenous injection of 33 per cent. glucose solution terminates coma and restores consciousness within a few minutes. The latter's action is so immediate that it is considered a practical rule not to stop injecting glucose until the patient is really awake.

From these observations coma appears to be a kind of trigger mechanism comparable to instinctive reactions, such as thirst, hunger or sexual desire. Once established it can only be reversed by specific means.