This pamphlet meets the food problem in an excellent manner and has arranged a number of proposed dietaries for working and custodial patients. I think it merits our careful attention and will give us a basis for working out many reforms in our food conditions, as it is all on a scientific basis.

In Ontario, Canada, the following letter has been sent to the superintendents of all the county houses of refuge and all the institutions receiving a government grant. It speaks for itself: "TORONTO, March 22, 1918.

"MY DEAR SUPERINTENDENT:

"One year ago to-day a letter was addressed to you asking your help, and saying 'The need for increased production of food is real and urgent.' A splendid response was made to that appeal.

"If the need of food was great last year, it is ten times greater this year. Last year Germany only was on rations. This year Britain is on rations, France is on rations, Italy is on rations. The British are denying themselves and going hungry. Starvation stares the French, Belgians, and Serbians in the face. Famine threatens the Italians.

“Our Allies depend on Canada and the United States for food. They are trusting to us. We must not fail them.

"If you have a farm, or if you know anybody who has a farm, see that at least five more acres of wheat are grown on that farm in 1918 than in 1917; and grow in your garden all the potatoes, peas, beans, beets, onions, carrots, parsnips and other food that you can grow, and do not let one foot of earth lie idle this year anywhere in your township, village, town or city.

"Every head of cattle, every sheep, every pig, every chicken we can raise is wanted, and badly wanted.

"Under Almighty God our hope of final victory and rightful peace is in the hands of our farmers, as truly as it is in the hands of our munition workers and in the hands of our fighting men.

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'Everybody can help-men, women and children.

'Do not waste any food-not a crumb.

"Be a leader and get everybody to help."

This work requires us, no matter what our nationality, to work together, not only in feeding our people properly, but at the same time by paying careful attention to conservation. Save a certain amount and the multiplication of that saved in all our institutions will be a very great asset for our nations.

Need I say more? Only this! In carrying out the solemn duty of doing our very best for the dear people God, in His Providence, has committed to our care, that we realize in like manner the importance in this crisis of doing all we possibly can for food production, and especially food conservation.

PELLAGRA AT THE CONNECTICUT HOSPITAL

FOR THE INSANE.

BY WILLIAM C. SANDY, M. D., MIDDLETOWN, CONN., Assistant Superintendent, Connecticut Hospital for the Insane. Pellagra has been found sporadically in most sections of the United States. It is this fact that has led one authority to assert that pellagra should not be considered a disease of the South, although so frequently observed in certain sections thereof, and that more cases would have been reported in other parts of the country had they not remained unrecognized. The rather widely scattered occurrence of pellagra, usually among the poorly nourished, may also help to establish the theory that faulty or improperly balanced diet is an important etiological factor. At least, it tends to the abandonment of the diseased corn theory of etiology. The infectious origin is still advocated by several eminent investigators who have sought to parallel the frequency of pellagra in Southern cotton mill villages with the absence of adequate sewage disposal facilities.

Much has been written upon the clinical side of the disease, and it has been shown that from a psychiatric aspect, pellagra is often associated with various psychoses, the effect frequently being to alter unfavorably the ultimate prognosis. It is not the intention at this time to enter into a detailed discussion of the various manifestations of pellagra. These are more or less familiar, especially to those connected with Southern institutions for the insane, and probably little if anything new could be added to the already extensive literature. During the latter half of 1917, however, there occurred at the Connecticut Hospital for the Insane at Middletown, five cases presenting clinical signs of pellagra. The rarity of the disease in this state and hospital, together with some atypical features has made these cases seem worthy of discussion.

According to a recent report, the first case of pellagra coming to the attention of the Connecticut Board of Health was a death in New Canaan in 1911. Following this there have been reported

several cases, in 1917 there having been six deaths from pellagra. The July, 1917, number of the Connecticut Health Bulletin contains the statement that pellagra "has been observed among negro tobacco laborers recently imported from the South." In the report already quoted, it is also stated that a former superintendent, for 30 years at the Connecticut Hospital for the Insane at Middletown, asserted that he had met with only one case, while at the Norwich State Hospital only two cases have been recognized.

In studying the histories of the cases under consideration, the type of the individual and the kind of psychosis are of some significance. It is quite apparent for instance, if one accepts the theory of faulty diet as the principal causal factor, that cases of dementia praecox or other psychoses in which there may be a tendency to take insufficient or improperly balanced nourishment, may prove to be likely subjects for the development of pellagra.

The first case, one of dementia præcox, paranoid form, after a hospital residence of over two years, presented the skin and mucous membrane signs of pellagra of a mild type, following persistent dietetic indiscretions. The physical signs of pellagra promptly disappeared when the patient was placed upon a rational diet, there still remaining, however, a few quite characteristic sequellæ.

CASE I. No. 16814. Admitted January 6, 1915. A white female, born in New York, age 30, married, Protestant, housewife.

So far as ascertained, the family history was negative. Fourth in order of birth of five children, her early development is said to have been normal. She received a common school education, making good progress and later acted as saleslady until her marriage in August, 1917. In disposition, she is said to have been mild, steady and temperate.

Menstruation began at 12, with no abnormality. She had two still births and one living child born June 2, 1914. The psychosis developed rather suddenly, seven months prior to admission, a few days after the birth of her living child. She became restless, fearful and depressed. She claimed her people were sick, injured or in trouble and it was necessary for her to see some court official in order to have this matter attended to. She had auditory hallucinations, being annoyed by vulgar expressions. When admitted, she weighed 971⁄2 pounds. She was anæmic, hæmoglobin 70 per cent, red cells 3,800,000, and a faint murmur in the pulmonic area (hæmic) was detected. She appeared confused and anxious, agitated by her auditory hallucinations, hearing her brothers crying for help. Later on she became clear and well oriented. Memory appeared fair. She had no insight and judgment was defective.

Following admission, she has usually seemed aimless and has taken little interest in occupation. She frequently smiles to herself and has continued to hallucinate. Has expressed the idea that she was poisoned and had contracted a loathsome disease; also that she was Jesus Christ and was suffering for the sins of the world. Upon several occasions has visited her home for a few days or weeks at a time, showing affection for her child but irritability and dislike for her husband. Her physical condition improved in respect to the blood picture.

On April 19, 1917, it was noticed that the patient had bilateral and symmetrical lesions of the skin, involving principally the extensor and to some extent the flexor surfaces of the forearms and knees, there being also a few lesions on the neck. There was a region of slight ulceration on the tip and edges of the tongue. The whole symptom-complex was very suggestive of pellagra. Upon investigation, it was found that the patient, ever since admission, had been accustomed to an exclusive diet of bread and sweets, taking practically no meat which she says she is unable to chew and does not like anyway. Every week her husband visits her, bringing fruit, candy and cakes, so that she had been eating very little in the dining room. She was placed upon a milk diet together with meat, eggs and other elements making up a well-balanced dietary. By July, 1917, she had improved in physical condition markedly and the eruption had entirely disappeared.

At the present time (March, 1918) there has been no recurrence of the skin lesion or other symptoms, but there is a roughness of the elbows often found in old cases of pellagra.

The second case, also one of dementia præcox, but hebephrenic form, after a hospital residence of about two years, during a part of which time she had to be tube-fed, developed the characteristic skin and mucous membrane appearances of pellagra. She was also tuberculous and finally died, the pellagra symptoms becoming more and more marked.

CASE 2.-No. 15574. Admitted September 15, 1915. Female, white, born in Connecticut, aged 31, married, Methodist, housewife. Information meager as to family history. Negative for nervous, mental and other important conditions so far as ascertained.

She was the youngest of four children, all girls, one of whom died from an unknown cause. At the age of seven, she is said to have had a head injury followed by a brief period of unconsciousness from which she made a satisfactory recovery. Aside from this, she is said to have been well during infancy, childhood and until present illness.

She made good progress at school, completing a grammar school and business college course, and for a time before her marriage, she worked as stenographer.

Her menstrual flow was always scanty. She married at the age of 23 and has had two children after normal pregnancies and labors. The younger child at time of admission of patient, was eight months old.

In disposition patient is said to have been sociable, mild but "nervous.” She showed aptitude both for study and work. She was temperate and not a user of drugs. The psychosis was gradual in onset. The first symptoms appeared about three months following the birth of her second child which occurred in December, 1913. She seemed depressed, walked the floor at night until she became exhausted, and refused to eat much food. She expressed ideas of infidelity and called her husband vile names. She was a patient at a private hospital from March 22 to June 30, 1915, when she was removed by her husband against advice. While there she was resistive, refused food, would not answer questions, was untidy and once highly excited. She had to be tube fed and remained untidy until the last 10 days of her stay when she began to eat well, dressed and undressed herself, and entered into normal associations with others, conversing coherently. She did not develop insight.

Upon admission at C. H. I. Physically there was considerable emaciation; teeth in poor condition. Blood Wassermann negative. She was a little restless but entered into the hospital routine quite readily. She was evasive but expressed no well-defined delusions and there was no evidence of hallucinations. There appeared to be much emotional deterioration. Conversation was rambling. Memory was good. Her insight and judgment of the situation were defective. A mental diagnosis of dementia præcox, hebephrenic form, was made.

Following admission she was seclusive, showed a tendency to remain standing a great deal although weak, and was unoccupied. She lost much in weight and developed signs of pulmonary tuberculosis; after which she became very untidy, expectorating on floors and walls. Around July

1, 1917, she developed an erythematous condition involving the backs of the hands, fingers and wrists, extending about an inch and a half above the wrists. There were also red and roughened areas on both elbows and at the suprasternal notch, and an eczematous condition of the nose, forehead and lips. The tongue became red and inflamed.

Despite extra diet and other special attention, she continued to fail, losing in weight. Her breath became foul, she was salivated and she developed a characteristic odor of an advanced case of pellagra, from which disease she finally died on August 16, 1917. Permission for postmortem examination could not be obtained.

The third case, one of dementia præcox, after some years of hospital residence in several institutions, developed pellagra symptoms. For several months prior to this she had persistently refused food and was tube fed. She failed to respond to treatment, death occurring about a month after the appearance of the characteristic symptoms.

CASE 3. No. 15632. Admitted November 16, 1915. Female, white, born in Pennsylvania, age 43, married. Congregationalist, housewife.

Father developed epilepsy after 40 years of age. Otherwise family history negative.