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this tendency some of its symptoms deserve mention. The mildest form is represented by those cases in which, after the subsidence of the fever, the patients fail to show their former physical and mental energy, they are dull and sluggish, very susceptible to fatigue; they cannot collect their thoughts and find it difficult to occupy themselves; are indifferent to their surroundings and let things go as they will. In emotional attitude they are sad and troubled, sometimes irritable, and occasionally at night they suddenly develop a state of great anxiety. In the severe types hallucinations of all the senses may be present, disorientation with confusion of thought, fantastic delusions and active excitement with anxiety. Emotionally, dejected and at times ill-humored, obstinate and resistive. Physically there is faulty nutrition and insomnia. It may be differentiated from dementia præcox by greater affect and disturbance of apprehension and orientation at the onset of the disease, and by the absence of negativism and stereotype movements; from the depressive phase of manic-depressive insanity by the absence of psychomotor retardation and the presence of faulty memory. The prognosis is unfavorable; after months of institution treatment, only one-half of the cases recover; the other cases improve gradually, but present as residuals weakness of intellect, poor judgment, inability to keep up with their classes, take up their former occupation, or provide for themselves.

A few cases are reported that seem to come quite properly under the heading exhaustion psychoses, as they apparently arise from excessive exhaustion or insufficient restoration of the nervous elements in the cerebral cortex. There is usually a history of a severe attack of scarlet fever, and evidence of a radical change of the physical organism. But even here one cannot always exclude the possibility of toxemia arising from the destruction of tissue.

Last, but not least, the relation of scarlet fever to dementia præcox must be considered, especially in view of the fact that so seldom can a definite or satisfactory cause for dementia præcox be ascertained. It is conceded, by good authorities, that, now and then, it follows very closely an attack of scarlet fever and bears a direct relationship to the same, but more often it is consecutive to some form of psychosis previously mentioned. It is the indirect relationship of scarlet fever to dementia præcox that suggests any ground for discussion. Years may have intervened be

tween the attack of scarlet fever and the onset of the psychosis. Cases have come under our observation at the New Jersey State Hospital at Trenton with intervals ranging from 7 months to 31 years, with an unquestionable history of the fever indirectly in fluencing the psychosis.

The disease may have been forgotten or recalled only after careful and specific questioning; at the same time we find a history of convulsions, a delirium, physical weakness, otitis, loss of energy, long or final absence from school or arrested development. Too often the papers committing these cases to the psychopathic hos pitals contain no statement whatever indicating the etiology of the psychosis; or such statements as overwork, mental strain, mastur bation, intemperance, ill-health, cigarette smoking, a fever, feeblemindedness, etc. On the other hand the examining physician encounters much ignorance on the part of the parents regarding the diseases their children have had. Such statements as "a fever" or "a rising in the head" are only suggestive, not to mention the great number of aliens committed to our hospitals who are prac tically out of the question.

Kraepelin, in his study of the etiology of dementia præcox, has found that in 10 per cent of the cases there is a previous history of some severe acute illness, particularly typhoid or scarlet fever, from which time the patient has exhibited some change, as increased irritability, susceptibility to fatigue, or impairment of the full mental capacity. From the records of the Trenton State Hospital, we find a case corresponding identically with this view.

CASE NO. 1.-F. C., male, white, single, age 24 years; occupation, laborer. Birth and infancy normal, strong and bright until six years of age, then had scarlet fever. Apparently good recovery, except mental dullness, more noticeable in his school work. Never independent of his parents, but earned wages. Admitted May 1, 1908. A year before admission a change in disposition occurred; he became seclusive and apprehensive; later suspicious of food, showed peculiar attitudes and mannerisms, was afraid to go to bed at night, had hallucinations of sight and hearing, at times untidy; disorientation and deterioration decided at the present time.

It will also be observed that the history of this case, prior to the onset of the psychosis, is practically the same as we find in those of arrested development or acquired imbecility, varying in degree rather than in symptoms. The following case illustrates this point.

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CASE NO. 2.-W. C., female, single, age 63 years. Family history negative. Personal history: Not unusual until eight years of age; then had an attack of scarlet fever with convulsions. Went to school very irregularly after this on account of her delicate physical condition. She could not keep up with her classes, became discouraged, lost interest in her studies and preferred to stay at home with her parents. After her first menstruation she became stronger in body, but her mental state remained impaired; never self-supporting, but a good helper in her own home. She continued on through life without any essential change except that now and then she had irritable and contrary spells. During the past year, symptoms of senile deterioration were observed. She would wander aimlessly about the house or away from home. Meddled with fire and matches, imagined she was going to starve, and had no clothing to wear; up and about her room at night, accumulating numerous and worthless articles. Committed to State Hospital October, 1908.

Again the question might arise, Why should the first case become one of precocious dementia, while the second continues a high-grade imbecile until arriving within the period of senile deterioration?

I might enumerate cases indefinitely, but that would simply add tedium without compensation. There is yet one condition that seems sufficiently important to justify a few additional remarks. As stated in the early part of this paper, otitis as a complication in scarlet fever has been recorded as high as 75 per cent in some epidemics, with deaf-mutism as high as 23.5 per cent, which makes a population surprisingly large and particularly susceptible to episodes which cause them to be sent to our hospitals.

CASE No. 3 illustrates this class. W. S. B., male, white, single, age 30 years; occupation, painter.

Born at full term, labor normal, fifth in line of birth, breast-fed; cut teeth, walked and talked at usual time. Strong and healthy child until about five years of age, when he had an attack of scarlet fever, discharge from both ears, lost sense of hearing, gradually lost his speech; later attended school for the deaf, learned the sign language and painter's trade, and was employed as carriage painter for four years in his home town; laid off because of slack work, became suspicious, irritable and threatening, homicidal and suicidal, carried razors and attempted arson; arrested and committed to the State Hospital. No deterioration. A prompt recovery.

In conclusion, first, allow me to repeat the words of Dr. Earle. "If insanity is to be diminished it must be by prevention and not by cure." Second, that scarlet fever is an etiological factor in the

psychoses and worthy of more consideration. Third, that it is more apt to be followed by complications and sequelæ and impair the future usefulness of the individual when it occurs during the evolution period; hence a most rigid quarantine should be insti tuted in each and every case of the disease and prophylaxis should be the "battle-cry."

THE GANSER SYMPTOM AND SYMPTOM-COMPLEX.*

REPORT OF FIVE CASES.

BY THEO. I. TOWNSEND, M. D.,

First Assistant Physician, Dannemora State Hospital, Dannemora, N. Y. Since attention in this country was called to the Ganser symptom by Dr. Adolf Meyer in the Pathological Institute for the New York State hospitals in 1904, Dr. A. H. Ruggles' article in the AMERICAN JOURNAL OF INSANITY of October, 1905,' and the able report of a case by Dr. Henry P. Frost at the 1906 meeting of this Association, published in the AMERICAN JOURNAL OF INSANITY of January, 1907, an interested outlook for this symptom has been kept by the present reporter. It is undoubtedly an hysterical manifestation, and it is with some hesitation that five cases of this admittedly rare disorder are presented occurring in a year's admissions. In none of these, however, was it developed other than spontaneously, nor was there a question of malingering— even in the case of one patient who afterward claimed that he had feigned the symptom.

The typical Ganser symptom-complex is a confusional state, with hallucinations, of rapid onset and short duration; hysterical features are present, and the patient, in addition to silly answers and talk, misnames objects with analogous names, or describes their attributes in a roundabout manner; the replies to questions are often incorrect or absurd, but show a good understanding of the question and a near relation to the correct reply. To this latter symptom the term "Danebenreden" has been given by the Germans. Ganser states that on recovery there is amnesia for the attack.

The symptom of "Danebenreden," roundabout talk, or "symptom of approximate answers," as Dr. Ruggles has aptly termed it, is said to have been observed in dawn states on awakening from hypnosis, hysteria, manic conditions, melancholia, alcoholism, dementia præcox, imbecility, and to be most common in criminals and malingerers.

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

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