This feebleminded boy was committed to a State Hospital by an Insane Commission. §. Two of these cases recovered from an acute psychotic episode but are still epileptic. * Recovery from the acute psychotic episodes but the underlying disease process still present. On examination shows: memory defect, auditory and visual hallucinations, delusions of persecution, Occasional outbursts of excitement. The physical examination was not remarkable except for a laryngeal huskiness and Argyll-Robertson pupils. There was albuminuria and hyaline casts. Wassermann on blood and spinal fluid negative August 31. Spinal fluid showed increased albumen and globulin and four cells. On September 17, spinal fluid Wassermann negative; seventy-seven cells, albumen and globulin increased, and mastiche shows slight change in the first three tubes. She received eight injections of arsphenamine, totaling 2.3 gm. between September 6 and 27. On the latter date she was discharged to her home, with almost complete remission of her mental symptoms. Arrangements were made for her to continue treatment as an out-patient. Her mental symptoms soon disappeared entirely, and she ceased to visit the clinic. From all reports she has continued to do well. The feebleminded boy and the epileptic girl were brother and sister and victims of congenital neurosyphilis. The mother died in a district State Hospital, where a diagnosis of neurosyphilis was made. Two years before her death her vision began to fail, and a diagnosis of glaucoma was made. For some weeks before death she was totally deaf in addition to her blindness. In the family, the oldest son was reported as normal until at one and one-half years he had a paralytic stroke and is now at Glenwood. at Glenwood. The second son was the patient we saw, a feebleminded lad of twelve with organic signs of neurosyphilis. The girl is ten, epileptic and feebleminded. The next boy is eight and is said to be normal and healthy in every way, (which I am inclined to doubt.) The last labor, seven years ago, resulted in a still born child. No opportunity was afforded in these two cases to determine the results of treatment. indi These cases deserve emphasis because all too frequently we are satisfied with determining that a person is feeble minded or epileptic, and fail to search in the background for any possible factors which may be remedied. We can not be very optimistic as to the results of treatment in any vidual case of congenital neurosyphilis, since frequently the symptoms are due to destruction and the causal organisms are no longer active. But we should always look for such causes and treat them when we find them. Only in that way can we be sure that we have not failed to help a case which might be helped. Also deserving of emphasis is the fact that the diagnosis "neurosyphilis" is best made by laboratory tests. Such tests will not tell us whether the case is paretic or tabetic, or even without symptoms, but they are far more accurate in determining the presence or absence of neurosyphilis than are any clinical tests whatsoever. For any who doubt this asseveration, there is an ample literature on the subject (Barrett, Southard and Solomon, Lowrey). Since lumbar puncture is so safe and easy a procedure, and since the examination of the spinal fluid is so accurate and valuable as an aid to diagnosis, it seems imperative to perform it in any case showing the slightest indication of the possible presence of syphilis of the nervous system. Indeed I am one of those who believe that no diagnosis of an organic nervous case is ever complete without an examination of the spinal fluid. I might quote many cases in support of this contention regarding examination of the spinal fluid, but two cases recently seen will serve to fix the point. A man of twenty-six was seen while visiting a friend who was called in consultation. The patient had begun vomiting persistently about three weeks after a minor head trauma and had been vomiting for about three weeks. Within three days he had gone into a muttering delirium, from which he could be roused to make a few incoherent responses. At the time we saw him he was semi-comatose, hallucinated, confused. Temperature 101°. Mouth dry. Chest and abdomen negative. Neck stiff, photophobia, positive Kernig: active knee jerks: pupils react to light. Ophthalmoscopic examination negative. We are obviously dealing here with a case of meningitis. Leaving aside for the moment any other considerations, the first thing to be done is a lumbar puncture. If a cloudy fluid is obtained, we immediately give anti-meningococcus serum. If the fluid is clear, the chances are that in a man of twenty-six we are dealing with syphilis, and we should immediately give some antisyphilitic treatment. Chronic meningitis, with clear fluid, is nearly always due to syphilis or tuberculosis, and in some instances to a superficial tumor. In this particular case, the spinal fluid contained 400 cells (90 per cent lymphocytes) per cu.m.m., there was increased protein, a positive Wassermann and a syphilitic gold curve. Two intravenous injections of arsphenamine sufficed to clear up all acute symptoms, and a week later the patient was entirely clear mentally and had no neurological signs of a meningitis. The second case is that of a man of forty-two recently admitted to the hospital. For four years he has been showing signs of optic atrophy. On admission he was totally blind and presented an advanced tabes as well as signs of paretic involvement. The spinal fluid gives typical and strongly marked signs of neurosyphilis. Although he had been seen by a number of physicians we are not able to learn that any one ever made a diagnosis of neurosyphilis or treated the patient on that basis. The diagnosis could have been made as soon as the symptoms appeared if the spinal fluid had been examined. In either of these cases, the diagnosis was easy to make if one bore in mind the possibility of syphilis, and realized that lumbar puncture findings constituted exact criteria. They are proper parts of diagnosis, prognosis, and often serve as a valuable index of the progress of treatment. A final word with respect to the treatment of paresis. The differentiation of paresis from other types of neurosyphilis is not always easy. For that reason it is often wise to treat. We have found that the expansive, excited types, if taken early respond better to treatment (just as they are more apt to have remissions) than do the depressed cases, or those in which the early signs are signs of deterioration. Group II. Feebleminded-Any diagnosis of feeblemindedness properly includes an estimate of the degree of defect (idiot, imbecile, moron) and whatever we know as to the cause (syphilis, organic brain diseases of various sorts-traumatic, infectious or malformative glandular disorders, hereditary types). It is only fair to say that in many cases we cannot be at all sure of the cause, and here we feel it is best to state the cause as unknown. So it is with the majority of the cases here presented. In two cases we are sure of an hereditary background. In two more we have a history of early disease affecting the brain. The balance are of unknown causation. In certain of these types, results may be expected from medical treatment. In general, however, the treatment of feeblemindedness is educational-that is the training and disciplining of the individual to the limit of the capacity to assimilate. One of these cases was committed to a state hospital. One was sent to a reformatory. Two have been sent to the school for the feebleminded. The balance are at home. The social difficulties of the feebleminded would form a large chapter. The commonest of all is, of course, backwardness in development. Often this is not remarked until the child fails to learn at the proper rate in school. Mere dullness or even extreme stupidity does not, however, necessarily bar one from the enjoyment of social life. But when the lack of intelligence and judgment bring the person continually into conflict with society, then the case reaches the physician. The conduct disorders of these patients were varied-forging checks, stealing, sex offences, perversions, running away, cruelty (of sadistic type) all appear. In general we have to fear offences against property and the person from the boys, and sex offences from girls. ease. Group III. Epilepsies - There are many types of epilepsy. Where the symptom convulsions is associated with some other type of disease process, we do not put the case in this group, but tend to reserve this grouping for the idiopathic cases. One case is called glandular and included here, because of uncertainty whether it is glandular epilepsy or epilepsy plus glandular disThis woman of thirty had no convulsions until a thyroidectomy for Graves' Disease. Along with her convulsions she showed signs of tetany. Following Jelliffe she was given parathyroid oneeighth grain by suppository, with considerable diminution in the number of fits. She had also well developed cataracts in both eyes so that operation was necessary to enable her to see. Discharged to her home, the convulsions recurred and she was sent to a state hospital, from which we have report that she is doing well on pituitary extract. The idiopathic cases are not remarkable. Thorough laboratory and x-ray study failed to reveal a cause. All the cases were treated with luminal in addition to diet regulation. It is too early to report on our experiences with this drug, but in general it has been good. This is particularly true in one case where, under the influence of hallucinations and delusions the man cut both wrists, one temple and one ankle in order to kill himself. For nearly a year he has done well with no recurrence of convulsions or psychotic episodes. Group IV. It is interesting to find no cases of alcoholic disorder, although perhaps not surprising in view of the small number of alcoholic cases received in the state hospitals during many years. Group V. The Somato-psychoses-The psychoses dependent on bodily disease (ordinarily called the symptomatic psychoses) are of great interest to us. Only one case, a man with attacks of excitement and anxiety associated with a decompensated heart, belongs definitely in this group. He recovered from his psychosis and the immediate decompensation, although, naturally enough, he is liable to further attacks. Two other cases, diagnosed dementia praecox because of the schizophrenic symptoms and the defect in personality when there was recovery from the acute psychosis, had complicating physical disease that might have been regarded as the cause of the trouble. In one there was an unrecognized diphtheria and in the other recent labor with possible uterine toxemia. The majority of the cases in the somatic group never reach the state hospitals. They are cared for at home or in the general hospital. This is theoretically sound, since the treatment of the mental disease is the removal or amelioration of the physical disease. senile dementia, presented a somewhat unusual symptom in the way of continuous pain in the ophthalmic and maxillary divisions of the right fifth nerve. He had had alcohol injections and peripheral resection without relief. Another alcohol injection was tried and, if anything, inGroup VI. Encephalo psychoses-Of the cases creased the pain. This condition, trigeminal of psychosis associated with organic brain dis- "neuritis," as it is often called, is apparently due ease, one, a case with an acute episode of depres- to a central lesion, and is not to be relieved even sion, delusions and clouding of consciousness, by ganglion extirpation (Sicard, Robineau and made a good recovery from the episode. Here Here Paraf, Rev. Neurologique xxviii, 1, 1921, p. 82). the skull was trephined and a small zone of de- Indeed such treatment usually aggravates the pressed bone removed at the site of a fracture. condition. There was no external depression to be made out, as is not infrequently the case. The x-ray, however, showed the depression of the inner table. The patient continues well, nearly a year after discharge. Incidentally, the x-ray is one of the most valuable adjuncts in the diagnosis of certain types of psychiatric cases. Another case, a woman of thirty-five, was brought to us on a stretcher on August 28, 1920. In March, 1918, she suddenly collapsed, but made a quick recovery, though she afterwards complained of numbness in the right side. In May, 1918, she had another attack also involving paralysis of the right side. Recovery in a short time. Married in July, 1918, and went for five months to Texas. In December, 1918, she became nervous and restless, and had another stroke, losing the use of her legs and voice and becoming incontinent. Throughout 1919 she continued ill, though she got about to some extent on crutches. In November, 1919, she had two convulsions. She then got worse, and in April, 1920, had a stroke in volving the left side. Then came violent jerking movements lasting about ten days. Since then, difficulty in swallowing. For two months or so completely bed-ridden. The significant findings in the examination indicated a double pyramidal tract lesion, blood-pressure of 220-250 systolic and 130-150 diastolic, and a heart lesion. A history of this sort in a person of her age naturally suggests syphilis as the causative factor. The blood and spinal fluid Wassermann was negative: there was increased protein in the spinal fluid and only one cell. This would indicate that it was not syphilis. On September 11 the patient became distinctly worse, had a convulsion, showed signs of a flaccid paralysis and died on September 12. The autopsy revealed some old hemorrhages in both hemispheres and a recent hemorrhage in one. So far search for spirochaetes has been unsuccessful, and the most probable explanation of her difficulties is to be found in her chronic nephritis. The many extraordinary features of this case may well be reserved for later discussion. Group VII. Geriopsychoses-The cases of senile psychoses happen to present certain points of interest. One of these cases, in addition to Presbyophrenia (characterized by fabrication to fill in the memory gaps) is not a particularly common type of senile psychosis (constituting 6-8 per cent of such cases.) The fabrications resemble the romancing of the inveterate liar, except that the patients are unaware of the inaccuracy of their stories, and are likely to change them rapidly. The prognosis, as of the senile disorders in general, is bad. Group VIII. Schizophrenoses - Twenty-two per cent of dementia praecox cases represent about the expectation, since approximately onefourth of the admissions to the state hospitals belong in this general group. Certain points are especially to be noted; two cases made an excellent recovery following an acute attack, after being under treatment for seventy-two and ninetysix days respectively. One has continued at home, doing her own house work and behaving quite normally for nine months and one has been working as a nurse for over six months. One additional case has made a good recovery after six months at a state hospital. Of course, no statement regarding cases of dementia praecox will pass unchallenged unless the evidence on which the diagnosis is based is presented. For the present, however, suffice it to say that all of these were cases in which the entire staff concurred in the diagnoses, and the results were as given. Emphasis is laid on these remissions because of a general tendency to regard dementia praecox a hopeless, progressive, chronic disorder. Kraepelin states, "I myself found real improvement in 26 per cent of my cases, when that of a few months duration was taken into account." He concludes that 12-13 per cent of the cases show a complete recovery "which, however, seldom lasts longer than three to six years." (VIII ed.) Accordingly it is clear that a blanket prognosis of progressive deterioration is decidedly misleading. In general the paranoid cases do not recover and the catatonic have the best prognosis. Two of our paranoid cases (of the mitis type) did improve sufficiently to resume community life, though still deluded. With the exception of three cases, all in this group were under thirty. Dementia praecox s essentially a disease of the young; a maiming and not a killing process. It is only occasionally that any other form of mental disease (except the paranoid types) continues for ten or more years. One of our patients was fifty-one years of age, but the disease process had been in existence for more than twenty years. Kraepelin found in 1094 cases that 6.2 per cent begin under the age of fifteen years; 47.2 per cent from fifteen to twenty-five; 35.8 per cent from twenty-five to thirty-five; 8.8 per cent from thirty-five to fortyfive; 2.5 per cent over forty-five. The cause of dementia precox is unknown. Heredity, infections and toxemias, organic nervous disease, defective personality, age and par ticularly adolescence, syphilis and alcoholism of the parents, mental over-exertion-literally scores of possible causes have been advanced. But dementia praecox occurs in those of good heredity, in the absence of any demonstrable infection, toxemia, or nervous disease, in those of apparently good personality, at almost any age, in the absence of any known syphilis or alcoholism in the parents, in both sexes, all races, under the most diverse conditions, and can be recognized, though not so named in the descriptions of the old writers as far back as our records go. It is probable that we now include in this group several types of cases which will eventually be separated on the basis of etiology. Group IX. Cyclothymoses-By contrast with dementia praecox, the prognosis in manic-depressives is always good for the attack although to be sure, some cases develop a circular type, or have successive attacks with very short clear intervals. In general, the depressions run longer than the manias, and the mixed types longer than either. The latter seem especially likely to exhaustion also. Emphasis is needed on the point that a mania or depression is not necessarily manic-depressive. Excitement is a striking symptom that may easily mislead, unless one makes a thorough examination. The worst excitements we have had to deal with up-to-date were those of two general paretics; the next worst, that of a chronic delirium tremens, and the next, that of a paranoid praecox. One may be misled into thinking the patient is depressed when it is really negativism or apathy. It is accordingly necessary carefully to distinguish between states of mania and of melancholia on the one hand and mania or depression of the manic-depressive type on the other. Our present reports indicate that five of our seventeen manic-depressive cases have recovered; one was killed by a train; the remainder are still in hospitals unimproved or only a little so. The important elements in the treatment of manic-depressive cases are: over nourishment, hydrotherapy by means of prolonged baths and packs, careful attention to personal hygiene and to the surroundings, avoidance of drugs of the hypnotic class, and time. At present we regard this process as a self-limited one, in which careful attention to the above points may do much to shorten the attack. Psychotherapy in the form of a thorough analysis of the background of the attacks is important, but only in the intervals between attacks, and not during the attack itself. It is in these last two groups that we find the greatest divergence of diagnostic opinion. This is because of the impossibility, up to now, of determining any exact tests of absolute differential value. Group X. Paranoic Psychoses—Paranoia in its numerous forms was once an important part of psychiatric nosology. With the Kraepelinian regrouping of mental diseases according to outcome, and the establishment of certain etiological groups, the term paranoia has been restricted to a very small group of cases, although we still recognize many types of paranoic or paranoid conditions. There is a neurosyphilitic form: certain cases occur in connection with epilepsy: in fact, a paranoid state may occur in association with each of the groups we have discussed. The differentiation is to be made on the basis of symptoms other than the systematized delusions. The majority of such cases have symptoms of the praecox type, and are so diagnosticated. When we have thus so far as possible classified all the cases, we are left with a residuum of about 5 per cent of admissions (in this series 4 per cent) which we cannot further diagnosticate than to say they are "paranoic psychoses," a clinical-descriptive term. That is, they are "undiagnosed psychoses, paranoic type." They do not seem to be paranoia, paranoid dementia praecox, or any other type. Possibly they belong to the paraphrenia group. One of our four cases was a case of true para noia in the Kraepelinian sense: the others could not with certainty be classified. Group XI. Psychoneuroses-Psychoneuroses are not so often seen by the psychiatrist as he would like. Only the very severe types, where "insanity" is suspected, or where the behavior of |