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Early life and development not unusual. Graduated from Wellesley College and taught school until her marriage in 1900. Has had four children, three male, one female, the youngest being born June 20, 1908.

In disposition she was very sociable and sunny, not easily irritated. Never showed great capacity for work. She is said to have been rather eccentric and of a romantic nature. Following the birth of her last child in 1908, she neglected her household duties, wrote letters in which she prophesied many dangers and mysterious happenings. She did queer things such as endeavoring to have an acquaintance adopt her youngest child, taking her father from a private sanitarium to try to heal him herself, trying to exercise healing power on a strange child, burning her children's books and playthings, at times becoming excited, and violent if opposed. Received treatment in several private institutions and the Norwich State Hospital. She showed marked religious trends of a peculiar nature. On admission, weight 116 pounds, height 5 ft. 3 in. Poorly nourished. Sallow complexion. Wassermann negative. She entered readily into the hospital routine. After a while, at times performed peculiar acts such as undressing and going to bed directly after breakfast, which she said she did in obedience “to the spirit.” She often talked to herself and reacted constantly to auditory hallucinations, being direct commands from God. Spoke of wondermen of the world” through whom she communicated her ideas. General mental organization good. Insight and judgment defective.

Following admission she remained seclusive, neat and tidy, occupied in her room in embroidery. Constantly hallucinating, the false voices often directed her so that at times for long periods she would be absolutely mute, inactive, with eyes closed, holding herself in bed in a rigid position, refusing food and necessitating tube-feeding.

In December, 1917, she developed an erythema on the backs of her hands and wrists which was symmetrical, and which later became a dermatitis with ulcerations. There were also a symmetrical roughness of elbows, a seborrhea of the face, salivation, a redness of the tongue and towards the end, diarrhea. She became greatly emaciated. Although given special diet and other appropriate treatment she failed rapidly and died January 10, 1918. The eruption had become considerably less marked before her death but the general symptomatology pointed to pellagra.

The fourth case was a colored woman, the diagnosis being dementia præcox. She had a positive blood Wassermann and had been given a series of mercurial injections. One month following the last injection after which the Wassermann had become negative, and about five months after admission, the peculiar skin eruption and mucous membrane changes made their appearance. She also developed an intractable diarrhoea and died in about 10 days after the eruption was first noticed.

Case 4.-No. 16514. Admitted June 4, 1917. Female, colored, born in Connecticut. Aged 42, single. Protestant, cook. Patient's mother, a white woman, is said to have been alcoholic and insane. Details as to her condition not ascertained. Patient is stated to have been result of intimate relations with negro hired man.

Infancy and childhood said to have been normal. She went to school from six to fourteen and made usual progress. Her occupation was that of cook.

In disposition she was shy and retiring. Details of her life otherwise meager.

Psychosis was of gradual onset during the past eight years. She developed the idea that she was white. She saw white faces as she looked in the mirror. At times, she would be noisy, excited, restless and talkative, at other times she would be dull and stupid. She put flour on her face and dressed fantastically as a young girl. Imagined her father was rich.

On admission she was well nourished. The only abnormality noted was exaggerated knee-jerks. The blood Wassermann was positive, the spinal Auid negative. Mentally, she was seclusive and reserved, neat and tidy in appearance. In discussing her peculiar notion about being white, she at times broke out in silly laughter. Spoke of wealth and social position. Would not cooperate in questions designed to test mental organization. Insight and judgment defective.

Following admission she remained seclusive, unoccupied and disinclined to talk or answer questions. In view of the positive blood Wassermann, she was given 13 mercurial injections, receiving a total of 23 grains of mercuric salicylate, the last injection being given on October 9, 1917. On October 29, 1917, the blood Wassermann was negative. In August she had a cough and some diarrhæa. At the time of her last injection she complained of sore mouth.

She continued as above, but gradually lost in weight. On November 20, it was noticed she had a peculiar roughness on the back of the hands with dark discoloration. This was accompanied by marked stomatitis and redness of tongue and oral mucous membrane. As noted above, she had not received any mercury for over a month. She was put to bed and given extra diet. She developed an intractable diarrhea with fever, rapid heart action and a considerable cough. The sputum examination was negative. The odor of the stools became very offensive. The general symptomatology seemed to justify the diagnosis of pellagra. She died on November 30, 1917. Unable to secure permission for post-mortem examination.

The fifth case was a rather high-grade feeble-minded female with congenital absence of the palate and a positive blood Wasser

a mann. Following a hospital residence of over five years, she developed the peculiar and symmetrical scaliness of the backs of the hands, associated with inflammation of the oral and genital mucous membranes and gastric disturbances. She had received

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mercurial injections, the last dose being given about two weeks before the development of the physical signs resembling pellagra. The skin and mucous membranes improved under treatment but the patient finally died a month later from cardiac degeneration. The patient appeared well nourished and there was considerable subcutaneous fat even at the time of death.

CASE 5. No. 14409. Admitted November 27, 1912. Female, white, born in Connecticut, age about 40, single, Roman Catholic, once worked in a corset shop.

Information meager as to family history. Negative so far as ascertained. Details of early life not obtainable. She stated that when she was about 12 years old, she had St. Vitus' dance which continucd for several months She had a common school education. In her earlier life, she worked for a while in a corset shop. For the 10 years prior to admission, she was an inmate of an almshouse. She was unmarried. Habits said to have been temperate. Onset of psychosis indefinite. There seems to have been no well-marked psychosis but perhaps rather a series of episodes. It is stated she showed “nervous" symptoms more so since the death of her stepmother some years back, after which she thought she ought to return to her father's house but her father could not stand her actions. She is said to have “attempted suicide” by the introduction of a hair-pin in the bladder. She was excitable and attacked others in the almshouse.

On admission, she co-operated well in the hospital routine. Physically, there were found cleft palate, carious teeth with offensive breath, speech defect due to palate. Knee-jerks exaggerated. Blood Wassermann positive.

Mentally, she was quiet and well behaved, neat and cleanly in habits. She expressed no definite delusions except the idea that she may have been poisoned, and the presence of hallucinations was denied although she said she once saw her stepmother following her death. She was well oriented. Memory and general mental organization good. Judgment and insight defective. Following admission, she continued to be well behaved, but occasionally a little fault-finding. She assisted in the dining-room and later on in the sewing-room. Around the early part of December, 1917, she had been in bed upon several occasions and for several reasons. Some months before she was in bed for ill feelings accompanying the menstrual period. During this time, her pulse was found to be so irregular and rapid that she was kept in bed as a matter of treatment. On account of a positive blood Wassermann, she had been receiving, mercury hypodermatically, the last dose being given on November 30, She had an abscessed tooth, and it was extracted by a consulting dentist. About December 4, 1917, she had a severe vomiting spell, and she was again put to bed. It was reported that she had burns about the rectum which the patient explained had occurred sometime before as the result of the application (by her) of cotton saturated with oil of cloves given her by nurse for toothache. When she was placed in bed, she was menstruating so an

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examination was deferred until the eighth, when it was found that there was considerable inflammation of the vagina and adjacent parts. Appropriate treatment was instituted by the woman physician.

There had also been a stomatitis and gingivitis, with marked redness of the tongue. After being in bed awhile, she developed a symmetrical scaliness of the backs of both hands. She had a continuous fever with very rapid pulse and complained of sore throat and vomiting. The latter became bile tinged. She appeared to be quite well nourished and is reported to have been a heavy eater. Notwithstanding this, the skin and mucous membrane appearance resembled somewhat pellagra, but the possible specific factor had to be borne in mind. Under treatment locally and special diet, the inflammatory condition of the mucous membranes cleared up to a considerable degree. She had much difficulty in retaining her food, however, and her heart action failed to respond well to treatment, there being apparently a marked myocardial degeneration. She gradually failed and died on January 4, 1918.

A post-mortem examination was performed of which the following is a summary :

Hours post mortem.-Forty-eight hours.

Description.-The subject is a female about 40, very well developed and well nourished. Skin white, soft and in good condition. There is a small abrasion over each knee and elbow, large brownish scales on the radial half of the dorsum of both hands, and roughening of the skin of the elbows. The hard palate is missing and there are only a few teeth, all in poor condition. On median section the fat is 2 cm. thick and the musculature is firm, dark red.

Thorax.-Costal cartilages cut easily. Mediastinum filled with yellow fat.

Lungs.—Each weighs 370 gm. The right lung is firmly adherent to the costal wall at all points except the apex. The left lung is free. There is no fluid in the pleural cavities. Both lungs float in water. There is some hypostatic congestion in both lungs. There is no evidence of tuberculosis.

Heart.—Weighs 230 gm. The pericardium contains the normal amount of fluid. The epicardium is very fatty. The heart is pale externally and on section the walls are thin, pale and contain many fibrous strands. There is no apparent valvular incompetence. The mitral valve has a small fresh vegetation on the anterior cusp and the endocardium below the valve is opalescent. There is some atheroma of the aortic lining. The arch and descending aorta are only slightly atheromatous. Coronary arteries normal. Measurements.Aortic

7.5 cm.
Pulmonary

7-5 cm.
Mitral
Tricuspid
Left ventral
Right ventral

..10.

cm.

I.

0.5 cm.

cm.

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Abdomen.-There is a heavy layer of subperitoneal fat. The mesenteries are very fatty, and the fixed organs are embedded in fact. There is no Auid or evidence of inflammation in the peritoneal cavity.

Liver.-Appearance externally and on section normal. Veight 1100 gm.

Kidneys.-Weigh 310 gm. The left kidney is large, soft, dark red and has two ureters which remain separate to the bladder. The capsule of both kidneys is somewhat adherent and the surface has a granular-like appearance. On section there is considerable increase of connective tissue. The markings are distinct. Spleen.—Weighs 70 gm. Apparently normal.

Uterus.—There is a conical tumor about 1 cm. long projecting from posterior wall, which on section has the whorled structure of a fibroid, but is of the same color as the uterine wall. The endometrium is thickened and edematous. On pressure a considerable amount of glairy mucous exudes. The right tube is adherent to the pelvic wall and to the appendix.

Brain.–Weighs 1400 gm. Nothing abnormal noted.

Anatomical Diagnosis.-Adhesions from old pleuritis, endocarditis acuta, myocardial degeneration (fibrous), absence of palate (syphilitic), adhesions from right pelvic peritonitis, skin eruption suggestive of pellagra. Cause of Death.--Myocarditis.

In studying these five cases collectively, there is found a rather striking similarity in several particulars. Four were cases of dementia præcox, having a peculiar type of personality with a resistive tendency and a disinclination to take nourishment properly. With a single exception, the pellagra symptoms developed after a hospital residence of two years or more, the exception being in a case of dementia præcox which had been in the hospital about five months. The latter and also the feeble-minded patient both had positive blood Wassermann and received mercurial treatment by injections, the pellagra symptoms becoming evident about a month after the last injection. Only one of the five patients responded readily to dietetic treatment with a favorable outcome. One of the cases of dementia præcox was further complicated by pulmonary tuberculosis, undoubtedly an important factor in the fatal termination. Another was most persistent in her refusal of food, it being impossible to institute successfully a proper dietetic régime. In none of the cases did a diet of corn or residence in the South seem to bear any etiological relationship, nor was there obtained any evidence of other members of the family having been similarly affected.

The skin and mucous membrane symptoms did not make their appearance in any special time of year, one case developing in

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