November 12, 1908. No marked change. Shows the same impairment of memory. Orientation is imperfect and she has no conception as to the length of time she has been in the hospital. She recalls the death of her daughter, but cannot approximate the date of her decease. She is less chatty, and falsifications are less pronounced. She volunteered the remark that her daughter had appeared to her in the doorway and conversed with her.

December 15, 1908. She is now oriented for place and nearly so for time, but mistakes identities of those about her. Says she has been here three or four weeks (really three months). “I came here the last of November " (September 23, 1908). "Dr. T—, who roomed up in the village, came to me on Main St., Bridgeport, and asked me if I would not like to go away. He came with me, took my clothes from me and left me here to be treated for rheumatism." There is still marked amnesia for events of psychosis.

Content and Train of Thought.-She is loquacious. "I wish I had the 'tism' out of my bones. Have had it now for two years-no-going on two years-well it is more than one year. My memory is at fault because I am so nervous and easily rattled. After my daughter died a year ago, I kept a little store and worked in a laundry." Denies her drinking habits. “Oh, I have tasted it when it was going round, I took some-drank with others." Falsifications and confabulations of memory are very pronounced. She thinks she has been here a month (really six weeks). She makes a statement and immediately makes another entirely at variance with it, apparently having entirely forgotten her first statement. This peculiar memory defect was the most marked feature of the psychosis. She not only has pseudo-reminiscences, but also reminiscences of these falsifications, and also for more remote events. She answers some questions accurately, showing fewer lapses and fabrications than at first, and appears to be trying to correct some previous impressions. Thinks now that the voices she heard talking to her about her daughter may have been imaginary voices. Emotionally, cheerful, jolly, humorous—is "happy that she is living." Still has wrist drop, but can extend index finger of right hand fully and the others partially; pain in hands, forearms and legs and some hyperæsthesia-marked clonus of foot-knee-jerks abolished; tremor and

ataxia.

June 1, 1909. Same condition prevails. There is considerable atrophy of extensor muscles of left hand.

CASE III.-M. L. Born in Bridgeport, Conn., of Irish parents, thirtythree years of age. Married; shop employee in cartridge works. Developed normally; received a common school education, but never cared for study. Father was very intemperate. No history of insanity or neurotic tendencies in the family. Patient was married in 1898 and a son was born January 13, 1899, which lived only a short time. Four years ago her husband left her and since that time she has consorted with other men and led a dissolute life. For seven years she has been intemperate, and her

mother writes she has had syphilis. Has never had delirium tremens. The present is the first attack of mental trouble, and was of sudden onset, about four months ago. Speech became thick; gait, unsteady. She became talkative and restless, and at other times dull and apathetic; suffered from insomnia. Habits were filthy. Memory was poor for all events. She rambled in her talk, was mildly delirious, saw people who were not present, handled an imaginary child, feeding it candy, and complained of getting the candy in her hair. Passed urine and feces in bed. She was entirely unconscious of her surroundings. Although her whole body was more or less paralyzed from alcoholic polyneuritis, and she had passed her urine and feces in bed, she declared that there was nothing the matter with her. She sang and talked at night and thought she could get up and walk. Imagined the attendant was her husband.

Admitted to the Connecticut Hospital for the Insane, June 24, 1908. Aural and visual hallucinations cannot be elicited. She mistakes attendants for former acquaintances. Is completely disoriented. Says the season is fall (June, 1908). In reply to questions as to place, she says she is in a boat, then remarked, "No, this is my home at Stratford, Conn." She comprehends questions, but recent past events cannot be recalled; says it is morning (really 4 p. m.). She shows retrospective falsifications of memory. She cannot tell her age, when she went to school, nor the date of her marriage. Fabricates-says she slept in the corner bed-but arose this morning and got into the one she now occupies. Says she sees her husband every night. "Last Thursday or Friday-I just forget now what day it was we took a trolley ride up to New Haven and had a fine time; then went to Savin Rock and stayed there a few hours and had dinner, and then came home." Asked about the dinner, she replied, "Oh, we had a fine dinner-about ten courses—and everything you could imagine to eat. But we did not go right home, but went to Seaside Park and sat out on the benches for about two hours." Says her father has died since she came here, she received notice of it yesterday and went to make arrangements with her mother this morning in regard to the burial. "I have seen you before with your wife, in New York, week before last when I was down there with Maggie. You treated me for rheumatism." In the emotional field she is subject to marked oscillations. As a rule she is happy and cheerful, but easily irritated and angered.

Physical Symptoms.—Quadruple paraplegia, from motor and sensory polyneuritis; wrist drop; ankle drop; pain and hyperæsthesia in affected areas, and over nerve trunks on pressure; some atrophy of extensors; pupils dilated and very sluggish to light and accommodation; fine tremor of tongue; chronic nephritis; impaired speech, gait, station, and general muscular weakness.

August 10, 1908. Still completely disoriented. Says she is in a boat, "Came here this morning in a boat from New York-this is a boat and we will be in Bridgeport in a little while. I went to New York last night and left my pocket-book there. I went to a show with another girl." Content of

thought is made up of fabrications and pseudo-reminiscences. She laughs and converses with Case II, whose bed adjoins hers, and seems very jolly and happy.

August 21, 1908. Polyneuritic symptoms not so marked, especially on right side, in both arm and leg, and wrist drop not so prominent. Speech not perceptibly changed. Cannot pronounce clearly the usual test words. Amnesia and pseudo-reminiscences continue. She now expresses fantastic and somatic delusions similar to those of outset. She felt of the counterpane and when asked what was the trouble, said, "Why, this is a dog skin and must have come from that dog I felt on me."

LUMBAR PUNctures Made:

SEPT. 9, 1908.

OCT. 13, 1908.

At the beginning of punc

ture..

PRESSURE.

..150 mm..

..130 mm.

At the end of puncture.... No more fluid could.... 60 mm.

be obtained

June 1, 1909.-Patient is now dressed and sitting up, and is much improved physically. She is still unable to pronounce test words, shows considerable impairment of memory, and is at times irritable and peevish.

SCARLET FEVER AS AN ETIOLOGICAL FACTOR IN

THE PSYCHOSES.*

BY EDGAR B. FUNKHOUSER, M. D.,

Assistant Physician, State Hospital, Trenton, N. J.

A glance at the evolution of psychiatry is sufficient to impress one with the fact that etiology has held a prominent place with psychologists from the mythical era to the present time. It is also noticeable that at different periods, different causes were considered sufficient to produce a psychosis. Certain forms of insanity have come down through the ages unchanged, but etiology has oscillated from the heavens to its antipodes. With this oscillation of the real or supposed cause, care and treatment has followed in a most natural order of sequence. When the aberrations were attributed to the smile of the gods, the favored one was looked upon as supernatural and venerated. When possessed of the devil, praying, singing of hymns, violent exorcisms and magical formulæ prevailed. Only when the etiology came within the confines of physical causes and human reason can we discern any real progress. It is said that Galen, the last of the great ones of the golden age, who wrote at the beginning of the third century, did credit to a twentieth century text-book. During the dark ages which followed, the science of medicine degenerated into an elaborate system of empiricism and mysticism, and demonology was reinstated as a controlling element in life. "The world seemed to be like a large mad-house for witches and devils to play their antics in."

We foster the modern view: a human being sick; physical causes; a hospital, light, airy, clean and comfortable; suitable and abundant nourishment, trained nurses, kindness, non-restraint, reason, liberty. But let us not be deluded. "The cost of giving the treatment has been materially increased, the recovery rate remains unchanged" (Bancroft).

The scientific study and treatment of the insane has met with signal achievement, but the results are far from gratifying.

* Read at the sixty-fifth annual meeting of the American MedicoPsychological Association, Atlantic City, N. J., June 1-4, 1909.

The ever increasing percentage of insanity tends to turn our attention to that genius, Dr. Pliny Earle, of 30 years ago, who said, "Very clearly, if insanity is to be diminished it must be by prevention and not by cure." The old adage is also quite appropriate: "He who cures a disease may be the skilfullest, but he who prevents it is the safest physician." As etiology necessarily precedes prophylaxis, so a careful study of each known and probable cause seems worthy of consideration.

Where scarlet fever originated is not known; descriptions are given of it by medical writers before the Christian era. To Sydenham we owe the name and its differentiation from measles. It is very generally disseminated, it has been studied in all parts of the civilized world. No race is immune. Whether it is due to the streptococcus scarlatinæ of Klein and Gordon, or the streptococcus conglomeratus of Kurth, or an organism resembling the meningococcus as isolated by Wadsworth, has not been determined. Mallory would seem to demonstrate that the cause of the disease is probably a protozoön. Age does not confer immunity; susceptibility, however, is in inverse ratio to the age, the greatest incidence being from four to eight years of age.

Hospital care of scarlet fever cases has greatly reduced both morbidity and mortality, 23.48 and 1.56 respectively, per ten thousand population, in the Boston City Hospital. The mortality for the State of New Jersey during the past five years is given as 2.49 per ten thousand. The percentage of mortality varies, with age and epidemics, from 33 per cent to 1.33 per cent. The death rate in the Municipal Hospital of Philadelphia in 5213 cases was 9.72

per cent.

Although the mortality and morbidity has been considerably reduced, yet with hospital care and modern treatment, complications and sequelæ that may lead to permanent physical or mental impairment continues very high, estimated at over 90 per cent in some epidemics. Albuminuria accompanies nearly all cases of severe scarlet fever, often with interstitial changes especially marked. McCullom finds a mitral systolic murmur in 187 of 1000 cases analyzed. Otitis varies from 10 to 75 per cent. This in turn has been the direct cause of 10 per cent of deaf-mutism in the State of New York, in Great Britain 23.5 per cent.

The nervous system also receives no little portion of the damage