Praecox. His manner was frequently light as well as his mood, and both out of harmony with the situation, and seemed to be an over-compensation for what he was apparently trying to cover up. Closer interview and questioning confirmed this, and brought out the following content of thought: Chiefly marital infidelity on the part of his wife, and earlier ideas of reference and persecution; personal ability to "see things at a distance." The patient asked for an interview a number of times but seemed to get nowhere. Finally he said, "I have a secret I wish to tell you. While at the Receiving Hospital in Detroit I kept everything from the staff and have been doing the same thing here, but I am afraid I cannot carry it through. My wife was unfaithful. My evidence is, just before coming here I called her up over the telephone, and without recognizing my voice she said, 'Is this Joe or Charlie? One is a Ford man. That sort of thing had been going for about two months. I got evidence but not enough for court proceedings. I told her things were not right and she said, 'I'll put you where the dogs wont bother you.' She meant where nobody could get into touch with me. She used to stand at her window and look down with the shades of her window drawn. I could see what she was doing through a mirror but not to whom she was signalling. Her actions even during the day time showed that something wrong was going on. She was pink under the eyes. You know what that means (sexual significance). I had no other kind of evidence. We broke up housekeeping. She had a sign at the window marked 'for sale.' It was taken down when I came back. I thought she was selling out everything and beating it' with Joe or Charlie.”

The patient is evasive when asked if anybody tried to poison him. He admits sending a bottle to the Board of Health. This was not returned to him. "At times I heard her in the kitchen stirring things in a pitcher. She never did that before, she was always prompt at meal time."

The patient then asks the physician to go with him to Detroit to get his brother-in-law on the telephone where he has a switch-board, and then permit him. (the patient) to call up his wife. "She doesn't know my voice. She thinks I am here. I will represent I am Charlie or Joe and thus have a chance to make a date 'on the going to bed stuff,' and see if she falls for it. I'll then get a woman detective and let her run it down. If I don't get it straightened, in time it will ruin me. I'd like her if she would cut out this monkey stuff. My father was against the match but I don't want her family to know anything except the brother-in-law I spoke of. It would kill her oldest sister who thinks the sun rises and sets in me."

The patient then reverts to his suspicions dating back to over a year ago when he imagined he was being taken for a German spy, and says that he has had no other trouble except with his wife, and that his one desire is to know who Joe and Charlie are. He then returns to his residence at the Receiving Hospital where he says, he was playing a part. "I had to do this or kill my own goat.” The patient then makes a more bold statement saying. "I know she has been keeping up relations with Joe and Charlie since I have been here. I was presented with the sensation that there were two

rooms, one like a court room, the other a bright room where people were dancing and having a high old time. I have the power of seeing things at a distance. In the court room I saw Joe and Charlie get out and go away into the dancing room. In the dancing room I looked in at the door and only saw a crowd of people. At home I have seen two people leaving at day-break." The patient says he is sure she has been unfaithful to him.

This note on the patient's mental condition was made on May 15. The physician suggested to the patient that he leave the case in the physician's hands and allow him to handle the situation, and if there was anything in it the physician would find it out Since that time the patient has been visited twice by his wife. On the first visit he was still somewhat suspicious, but on the second visit this had apparently disappeared.

Today, June 9, he states that from the moment the physician said he would handle the situation he was sure that his wife had stopped all of her queer actions, and he wishes to look upon the things as completely of the past and forgotten.

He has enough insight to see that his father and mother are taking the part of his wife and be believes it would be unwise to pursue the matter any further.

The manner of the patient is still somewhat unnatural. He laughs rather light-heartedly in referring to certain things. Will not quite admit that he does not still have the power to "see things at a distance" but believes that he had better "cut out that stuff."

Comment. The case first looked like a simple post-infectious psychosis following influenza, but on close study of the case, particularly with reference to the patient's paranoid ideas for a year preceding his influenza, and because of the persistence of this paranoid tendency, particularly with reference to his wife, we seem rather to have a psychosis, not post-infectious, but a frank psychosis precipitated by a physical letdown. The features are those of paranoid Dementia Praecox, which is suggested by the paranoid tendency existing long before the influenza, and by the ideas of marital infidelity and telepathic ideas, which the patient still insists he has. This diagnosis is also confirmed by the patient's general manner. Alcoholic paranoia is with difficulty ruled out because of the history of long standing and steady alcoholism; this was confined, however, to beer drinking, on an average of a glass or two a day. While the patient's reactions do not appear to be those of alcoholism it is difficult to rule out the influence that it may have on the general picture. While on the whole it looks like a case of Dementia Praecox this should by no means be regarded as an absolute diagnosis.

CASE VII. Psychiatric Service 2528, H. T. Female, Age 27, Occupation, Housemaid.

Family History.-The father and mother separat

ed. Mother is a prostitute and a bad woman in every respect according to the anamnesis furnished by the State Industrial Home for Girls at Adrian. On one occasion she threatened the prosecutor and herself.

year.

Personal History. The patient was admitted to the State Industrial School in 1904 and discharged in 1910. She was reported as willful and vicious at times, and attended school only when compelled to do so. This was before admission. Her record at the State Industrial School is that of a good girl unusually quiet, capable and trusty. She had the usual diseases of childhood with good recovery. She had frequent pharyngitis and tonsillitis during childhood. Headaches about once a month to the twenty-fifth. For the past seven years there has been pain over the right ovary at the beginning of the menstrual periods. Two and a half years ago she had a severe attack of tonsillitis, lasting about three days with elevated temperature. Two years ago while working at the Belding Silk Factory the patient became very nervous. As this "worked on. her" it affected, according to her own account, her right knee so seriously that she could not keep up her work. The knee "bothered" her for nearly a year and a half. The pains in the knee suddenly got better, but became more intense in the right inguinal region. She came to the Homeopathic Hospital for treatment for this condition on February 23, 1919. Two days later she insisted on leaving the Homeopathic Hospital against advice, wandered about the town for several hours and was finally brought back by a Y. W. C. A. worker. The patient had fifty dollars on her person when she left the hospital. It was gone upon her return. A few days later she developed more marked mental symptoms, was referred to the Psychopathic Hosital and admitted on March 14.

Course Here. Physical Examination.—Negative except for apical abscess of a right molar which developed two weeks after admission,

Gynecological Examination.-Negative except for pruritis vulvae.

Neurological Examinations.-Negative.

Laboratory Examinations.-Negative except for a number of W. B. C. in the urine, probably from the pruritis. Blood count at the Homeopathic Hospital February 23, 1919, 13,600 WBC. Blood count here negative.

Mental Examination.-Ever since admission to the hospital the patient has had the appearance of being perplexed, apprehensive and unclear. In view of this attitude and of the subjective account of "knee trouble" it was at first thought that we were dealing with a case of post-infectious psychosis following articular rheumatism. Communication with the Homeopathic Hospital and with the family physician elicited no history, however, of any recent illness or febrile condition. Routine mental examination brought out the following points:

1. General appearance that of mild apprehension and slight unclearness. The patient tries to cooperate, however, at all times. She is quite respectful, and accessible, though slow in her movements and in her speech. She frequently looks at the examiner in a perplexed way, gazes about the room as if hallucinated, and appears to be in a dream state.

2. All movements, as well as speech, are slow, either the result of psychomotor retardation or of blocking. Occasionally she replies to a question several minutes after it has been asked, and seems especially eager to reply if the examiner prepares to leave the room,

3. Sleep: The patient complains of not sleeping well. She reports frequent dreams, but when questioned as to whether she is sure they are dreams. she hesitates and says, "Perhaps I think

I thought it last night." Her "dreams" are of great significance. The following is typical: "I dreamed I went somewhere and saw men and automobiles. One man had dark eyes and was a German. I saw two babies; one was asleep, and the other wasn't; one was crying and the other had its eyes open. Then I went into the house and I seemed to have blue eyes and light hair (the patient has dark hair and eyes) and I was glad and happy about it." It is this dream (?) that she thinks she "thought." 4. Comprehension: is not disturbed, but the patient's attention frequently lags seemingly because she is lost in her own abstractions.

5. Stream of thought shows almost as typical a blocking as it is possible to see. She starts to reply to a question, seems to have forgotten it, hesitates, begins again, sighs, and when the examiner asks another question she replies to the first. It frequently resolves itself into an ambitendency or ambivalency. This will be seen in the narrative of the patient. It is the same in respect to purposeful movements. She begins, then stops. At times she has had a retention of urine. When taken to the toilet she sits for a long time, says she cannot pass her water, but wishes instead to be allowed to defecate.

6. The Content of Thought shows two interesting features: auditory hallucinations, and desire. as she puts it, "to have a man." About this desire "to have a man" is woven an extremely interesting sexual fantasy. In her own words. "A year or two ago I used to masturbate. I felt sorry afterwards and thought it was wrong. Then I used to think I wanted to get married, but I never found the right man. Some wanted me, but I didn't like them. Before my knee hurt me at Belding I decided to go West: I felt nervous. I thought I would go and get a man. I went to Colorado, Denver, and worked at a restaurant. One day a man came in. I cared for him, perhaps he cared for me. He didn't say anything, but he wrote me after I came back. I thought I wanted to marry him. I liked the looks of him. I thought he was 36. but he was really 51. Now, that is strange, isn't it?"

At another interview the patient states that eight and a half years ago her father used to come to her and place his genitals against hers, but never made intromission. She would handle his parts. Three years ago she did the same thing with a cousin, and again for three or four times with her father last September. (Gynecological examination shows imperforate hymen).

While at the Homeopathic Hospital the patient made a suicidal attempt. When asked the reason she answered, "Because I was afraid I couldn't see my father again. I wanted to tell him I was sorry." Also, while at the Homeopathic Hospital she says she heard the voices of girls saying, "You like your father, you slept with him, and I thought that was

wrong because that is the way married folks do. There I said strange things such as "Father pissed in it, and mother shit in it." My father was there when I said those things. That is why I want him to come. to tell him I am sorry."

At this hospital she has heard voices say, "You cheated, because you liked your father." Then the patient says in comment, "I liked my father because I liked everyone, I guess." Then she looks questioningly at the examiner asking "That's all right to like everyone?" Then breaks off rather abruptly and says, "But you can't like everyone. Then the voices said they were going to cheat me; they meant they were going to prevent me going out with a gentleman friend, Americans I guess, not Germans." When asked how one can hear voices she replies, "I hear voices in my mind. I don't know as I hear voices, but I think I hear them."

7. Orientation. The patient is oriented for person and place, but only partially oriented for time, missing the day and date, but giving the year and month.

8. Narrative. This was given in the form of the patient's own anamnesis. When questioned about incidents of the day when she left the Homeopathic Hospital, she states that she left the hospital about 11 a. m. and walked steadily until about 2 p. m. It seemed as though the doctors were after me to see how far I could walk to test my heart. I went to the Ann Arbor restaurant for dinner. Once I went into a shoe store to send a telegram; then to a grocery store; I was looking for the depot to send the telegram to my father. When questioned about her money, she says she gave it to her father. She becomes somewhat confused at this point, knowing her father was not in the city, but insists that she gave it to no other man. After lunch she returned to the Y. W. C. A., and says while there she felt sick, as though she were going to die. It was after this that she was returned to the Homeopathic Hospital.

I

9. Insight: Is not perfect. She knows she is nervous and worried, but she has no complaint except "a pain in the side." When asked why she looks about the room in so strange a way she answers, "I feel as if something were on my head drawing it, a machine of some kind." She then looks at her hands and says, "I am not clean, yes am clean, but I am not clean inside. My blood is gone. Sometimes I have quite a bit, and then I don't have very much. I think it is caked." (Do you feel changed?) "Not until last night when I thought I had light hair and blue eyes, but I liked them last night. I thought she was a German girl." 10. Ward Notes, April 9, 1919.

The patient is clear, well oriented, knows that the physician has been away a week; gives the day and month correctly; misses the date by two days. She states that the feelings of her head of being drawn as if by a machine have disappeared, and that things seem more real except when she thinks too much. When asked what she thinks she gives a reply that is evidence of auditory hallucinations: "I hear them saying that she is going to have a dirty rotten baby. I can't see how that is." She then looks out of the window in a perplexed way and continues, "I saw a soldier this morning and thought I liked the looks of him. He looked as if he was waiting for something, to see what I was

I was

going to do in the window, but I wasn't. going to put the window up. I hear someone say 'throw it,' 'throw it.'" (Throw what?) "A touch of passion I guess. I don't understand that very well. A touch of passion I guess. I don't understands that very well. A touch of passion for children, I guess." When questioned about her somatic complaints she states that she now feels more like herself than when she came into the hospital. She has no pains in the side, "No pains anywhere."

For the past two months there has been no noticeable change in the patient's condition unless it is a slight deterioration. Her manner is more frequently silly and there is frequent unmotivated laughter. She insists that she still hears voices. There is still evidence of blocking. Her replies when she is interviewed come with abruptness and in a choppy manner, with long intervals between questions and answers. The answers are frequently explosive. She has been erotic at all times. She continually says she wants a man to sleep with her and asked the physician if he would not do so. When asked why she laughs when she is touched on the arm she replies, "Because it gives me pleasure." There have been one or two brief episodes of excitement when she has imagined that the Germans and Catholics are against her.

Diagnosis. The diagnosis in this case is one of the most difficult of all the cases considered. She seems to present a picture and difficulties quite similar to one or two of the seven cases presented by Hoch and Kerby in the April number, 1919, of the Archives of Neurology and Psychiatry under the caption, "A Clinical Study of Psychoses Characterized by Distressed Perplexity." The principal features in these cases are:

1. Perplexity in facial expression and utterances. 2. Marked distress accompanied either by restlessness or phenomena of inhibition.

3. A feeling of guilt which the patient cannot formulate; which is projected in the form of accusatory hallucinations against which the patient protests, that is, does not accept.

4. There is often a constitutional basis and the psychosis is frequently of apparently short duration. Quoting Hoch exactly: "As to the clinical position of these cases, it was shown that the reaction as such has a certain relationship to the manic depressive reactions, that features of it, and possibly the pure clinical picture, may occur of a toxic infectious etiology, and also in typical form. It has occurred in a case whose further course was that of Dementia Praecox." It was pointed out that the same is true in the case of the manic and stupor reactions.

Hence the case before us seems to lie between a depression with perplexity; a toxic infectious psychosis with perplexity, and a dementia praecox with perplexity. It is rather hazardous to risk a positive diagnosis at this stage. The history of unclearness, however, on the day the patient wandered away from the Homeopathic Hospital and the evidence of fantasies of a sexual nature, with pronounced wish-longings, together with ambivalent tendencies point somewhat strongly to dementia praecox. Whether the perplexity in the case is due to negativistic and agnostic impulses, or whether the perplexity produces what appears to be either retardation or blocking, it is hard to determine. Ex

cept for the dream (?) in which the patient conceived herself as having light hair and blue eyes, there is no positive evidence of disintegration.

However that may be as the case progressed one could almost see the unfolding of the schizophrenic mechanisms with an effect not unlike the ultra rapid moving picture device which enables one to get the most rapid and complex movements of the athletes' gymnastics. Unlike case six there is no definite evidence yet of progressive deterioration.

Case VIII. Neurological Service. Courtesy of Dr. C. D. Camp. R. G. Female, Age 40, Housewife. Married.

Family History.-Two aunts and uncles have epileptic seizures.

Make-up.-Eighth grade education at fourteen. Somewhat nervous all her life. Given to day dreaming as well as night dreams.

Personal History.-Sick headaches all her life, but not severe enough to confine her to bed. Five years ago they became more severe and have been worse in the last two years.

Present Trouble.-Dates back about two years. Headaches began in forehead involving the back of neck, and lasting as long as five days at a time. During the attack she has photo-phobia; is nauseated and sometimes vomits. She also experiences numbness, but has had no disturbance of visions. She sometimes falls backwards; feels herself "going" but cannot talk. These attacks are only momentary. The headache ceases after her "falling back."

Examination. Facial expression somewhat epileptic. Teeth show pyorrhea. No paralysis. Considerable medium tremor of extended hands. The pupils react somewhat sluggishly. Anesthesia of the conjunctivae on both sides. Hearing on the left somewhat obtunded. Optic nerve on the right eye pale and deeply cupped.

The above history and examination was made on December 11, 1919. Diagnosis-Migraine.

The patient returned March 20, and states that four weeks ago she was taken sick. Since then she has had nasalized speech. She has become weak and says that she has had tremors of the hands. She is now so weak that she cannot walk alone. No diplopia. She complains of continual sleepiness, being able to sleep at any time and anywhere. The husband states that she falls asleep in a chair. The face is expressionless, rarely winking. Pupils unequal, right being larger than left. Slight bilateral ptosis. She does not draw back either angle of the mouth in showing the teeth. The teeth are dry, The teeth are dry, gums sore and red. On sound formation the soft palate rises very slightly to the left. There is a

marked intention tremor equal on both sides and occasionally a slight tremor at rest. Knee jerks negative. Intention tremors in both legs. Pulse weak, fairly regular, 120 per minute.

Laboratory Examinations.-Lumbar puncture two cells. Carbolic faintly positive. Both phases of the Nonne Apelt test, negative. Reducing substance normal. Blood Wassermann, negative. On two different occasions Spinal Fluid negative. Curve 00011100000.

Ophthalmology reports negative fundus.
X-Ray. The head negative.

Gynecology Examination.-Negative.

Gold

Diagnosis on Second Admission.-Lethargic Encephalitis.

The case was referred to us March 28, 1919. The patient appears apprehensive, restless and slightly emaciated. There is a moderate psychomotor retardation, and marked facial tremors, particularly at either angle of the mouth when the patient is speaking. It is a nasalized speech and different, according to the patient's statement, from what it is when she is well. Handwriting is tremulous. Sleep: The patient states that she dreams a great deal. Before coming here she dreamed of her father coming back to her. She states that she has always liked him better than her mother. Comprehension is unimpaired but there is a slight distractibility of attention. The patient is apprehensive about the outcome of her illness, frequently asking what is the nature of her trouble, and when she can go home.

The chief item of interest in the case is the patient's narrative. She states that shortly after she was married (that was 22 years ago) she wondered if her father would approve of the marriage. Shortly after that he appeared to her as in a vision saying "Babe don't worry." Since that time she has not worried about her marriage. She states that she has always been sexually frigid, and then repeats the account noted by Dr. Camp of fainting spells -that they existed for about three years; they are precipitated by disconcerting or unpleasant situations. Her vomitus is frequently watery. She does not lose consciousness, although everything about her seems dark. During these attacks there is Astasia Abasia, generalized body tremors, globus hystericus and gastric complaints.

She gives a history of having an almost complete aphonia previous to her present illness; that she had nothing but a whispered voice, even though she was not suffering from an ordinary cold.

Last summer, she states, that her mind seemed as if it were outside of her body. She tried to say things but could not. On certain occasions she reports what appear to be auditory hallucinations. She could hear the voices of her son and daughter when she knew they were out of the house or asleep.

Neurological Examination for sensory changes shows tenderness on pressure over erogenous zones. She has a general hyperalgesia. This appears to have come on since her lumbar puncture.

This last case is extremely interesting from several points of view. First of all clinicians and pathologists are not quite agreed on just what the term "lethargic encephalitis" denotes. Saint Martin and Lhermetti report two cases which they call "primary poliomesen-cephalitis with narcolepsie." They insist that the two fundamental symptoms in this disease represented by these two cases are complete bilateral paralysis of the third nerve, and hypersomnia. For this reason it is to be differentiated from the acute hemorrhagic poliomyelitis of Gayet-Wernicke which show symptoms not found in their cases, symptoms such as mild delirium, unclearness with hallucinations, changes in the reflexes, speech disturbances, mild facial palsies, sometimes even hemiphlegias and especially cere

4. Bull. de la Soc. Med. des Hospitaux, 17 May, 1918.

bellar symptoms such as tremors, ataxia, asynergias, and finally infectious or toxic processes. None of these exist in their two cases which they look upon as non-infectious, non-toxic because of the general condition and very mildly elevated temperature. Hence their cases should not be confused with "lethargic encephalitis" of the human trypanosome where the lesion is more diffuse involving the cortex of both the encephalon and the brain-stem. They also speak of a syndrome, more like a toxic psychosis which deserves the name of "infectious encephalitis."

In the same bulletin under date of May 24, 1918, Marie and Tretiakoff report findings on two autopsied cases as follows:

1. Acute inflammatory process at the level of the isthmus of the encephalon.

2. More marked inflammatory processes in the region of the cerebral peduncles with the superior limit passing through the basal ganglia and the inferior through the lower portion of the bulb.

3. Cord, Cerebral cortex and Cerebellum negative.

4. Lesions primarily in the gray substance of the regions noted with Wallerian degeneration of the fibres.

5. Histopathological (a) H. & E. stain shows ruptured vessels and small hemorrhages with infiltration into the parenchyma. (b) Bielchowsky stain shows that pathological changes attain their maximum at the level of the locus niger (section of crus cerebri between the tegmentum and the crusta). After this the most pronounced change is a very marked inflammatory process of periventricular gray matter, especially in the region of the nuclei of the third cranial nerves. Marinesco reports three autopsied cases: two of them with lesions in the floor of the fourth ventricle and in the aqueduct of Sylvius; and one with lesions in the cerebellum. He finds a plasma cell infiltration through the parenchyma in addition to that in the perivascular spaces. In these regions the nerve cells are not

THE TOLL OF THE NURSES.

A sacred constellation of one hundred and eighty-four gold stars on the service flag of the American Red Cross Department of Nursing at Washington is the silent token of the supreme sacrifice made by that number of American nurses. The record is still incomplete and when this roll of honour is finally closed it is probable that the names of fully two hundred American women who have laid their lives on the altar of freedom will have been inscribed upon it.

Death came to American nurses in many forms. Striving against hopeless odds to check the epidemic of influenza that swept over the training camps in this country last fall nearly a hundred nurses themselves succumbed to the scourge. Many more were victims of the disease when it

affected and thus the disease differs from poliomyelitis. But he does find nerve cell degeneration in the Locus Niger and in the Locus Caeruleus, (pigmented eminence in the floor of the fourth ventricle). He thinks the infection is by way of the lymphatics, the lymph-nodes and the mucous membranes. He too insists on the distinction from the

polio-encephalitis of Wernicke.

The case before us is not, then, like the two reported by Saint Martin and Lhermetti as "primary polio-encephalitis with narcolepsie;" but because of the neurological findings is more like the so-called "lethargic" cases autopsied by Marie and Tretiakoff. In addition our case presents further diagnostic difficulties in that we have an infectious process with neurological abnormalities in an individual whose past history is that of an hysterical type, and in whom hysterical stigmata still persist. These stigmata rule out consideration of dementia praecox, in spite of the history of hallucinations.

In conclusion, then, it is quite evident, as stated in the opening paragraph that the neuropsychiatrist is confronted with very troublesome problems of differential diagnosis when he meets psychoses associated with infectious diseases which might be mistaken for true psychoses in relatively mild forms, but in the acute stages. Hysteria and Dementia Praecox offer the most troublesome details of the difficulties. Moreover, there are certain obscure cases, such as Case III, which may run a long course, and in which both physical and mental conditions may parallel each other. The danger in such cases seems to be that of over-looking the infectious or toxic element. This particular case reveals the necessity of correlating neuropathological with clinical findings. The same necessity is apparent from what was said under the subject of lethargic encephalitis.

raged in the war zone. Ministering to the wounded in France other American nurses were killed by Hun ruthlessness in airplane raids.

But the American nurse who gave her life to the cause of Liberty did not die in vain. Into the shadowy beyond there went with her the prayers and murmurs of gratitude of those she succored. High military leaders gave their word of praise and appreciation for faithfulness that never faltered, while in homes saddened by the loss of the loved one there is imperishable pride.

Tuberculin "B. E." (Bacillus Emulsion)-Lederle. -Marketed in vials containing 1 Cc. For a description of New Tuberculin, see New and Nonofficial Remedies, 1919, p. 280. Schieffelin and Co., New York.