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ing of the upper lip — particularly on the left side. There was slight stiffness
of the elbow joints. No pathologic alteration of the reflexes of the pyramidal
tract signs was noted. There was normal sensory status.

Clinical Course. — There was nothing strange in her attitude or behavior in
the ward, beyond a drowsiness which gradually went away after the first few
weeks and a slight difficulty with facts of time. She was clear regarding people.
During the nights she talked in her sleep, but when awake she expressed no
strange or delusional ideas.

By the middle of May, 1920, she had made virtually a complete recovery and
was discharged.

Subsequent Course. — In July, 1920, she returned to her usual office work and
has been able to carry on duties presumably satisfactorily to her employers.
But when interviewed in October, 1920, she complained that her "memory is
very bad and not improving. I am more absent-minded than anything else."
She explained the fact that she had done the same variety of work without



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complaints from employers by saying, "Yes, but I make notes of everything and
do not trust my memory."

Tests revealed no demonstrable defects. Memory for the remote past was
strikingly good when questioned on family and personal dates (poor when deal-
ing with school knowledge).*

She repeated seven digits with rapidity and persistent accuracy, and showed
no attention defect.

Regarding mood, one noticed a tendency toward elation. She remarked
with considerable gusto, "I am more optimistic than I was before and I'm
happier." That this mood was not obviously pathologic was shown by the fact
that the sister had not noticed it. Yet when questioned, the sister admitted
that the patient was going more to theaters and to dances than before her ill-
ness, that she needed no urging to join any social occasion and that she was
keeping poor hours. The patient then explained, "But, I feel so restless. I want
to be on the go all the time." This restlessness showed itself also in an*
increased attention to her clothes and to the dressing of her hair, etc.

The mother' of the patient, who was also interviewed, believed that the
patient since her illness had shown a poor memory. But such examples as she
gave were better examples of a certain carelessness, hand in hand with her
mood. The mother complained that the patient "hasn't the right ambition yet"
— ^as she did have prior to her illness.

The patient recounted all features of her illness, and- showed absolutely no
amnesia. She was able to recall the dreams which caused her to talk in her
sleep so persistently. "I imagined terrible things at night, but never expressed
them — that accidents might happen to the family. I could see them happening."

Case 4. — Meager education. Sociable disposition. Onset with nervousness
and vague fears, then somnolence. Oculomotor symptoms, partial left hemi-
plegia and pseudo parkinsonian syndrome. No delirium or delusions. Short
course. Follovmg illness has shown a change in mood and lack of interests
with seclusive tendencies. Slight physical residuals.

Family History. — R. S., aged 42, Hebrew, shoemaker, admitted to Bellevue
Hospital, Sept. 29, 1919. The family history was negative for nervous and
mental disease. He was born in Russia. His schooling was scanty anrf included
barely two years of study. Prior to coming to the United States (at the age
of 27) he had spent six years in South Africa. His work there was divided
between harness-making and cobbling. For a time, he owned a small shoe-
store of his own. His habits were quiet. He disliked drinking, took small
interest "in women" and married at 28. As a boy he is said to have had good
health and to have been active. Yet he avoided rough games and found his
chief pleasure in rather excessive reading. He could skate and swftn. Prior
to his illness, he took a lively interest in socal affairs, often played card games,
etc., with a neighborhood circle. He was always known to be jolly and not
given to gloomy periods of any character. In later years, he lost interest in
religious affairs though previously he was taught and was inclined to be
orthodox.

Present Illness. — His illness began one month before admission to the hos-
pital with severe headache, "like neuralgia," and occasional vomiting. He was
nervous and "felt afraid" in a vague way without clear-cut ideas regarding
any cause for this. Although he was sleepy, he did not stay in bed. His
vision was dimmed and off and on he saw double. He came to the hospital by
automobile.



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Examination. — On admission he -was more or less somnolent with slow
reaction time, although able to answer questions rationally. He showed a
bilateral ptosis with inability to converge or depress the eyeballs to a normal
extent. There was a slight deviation of the tongue to the left, weakness of
the left side of the face, with a bilateral masklike -expression and weakness of
the left arm and leg. However, there were no pathologic reflexes. The sensory
findings were normal, likewise the fundi. There was fever for only a few days,
not rising above 101 F. The serologic examination showed 7 cells per cubic
millimeter in the spinal fluid.

Clinical Course. — There was no disorientation; also no hallucinations or
delusional ideas. There was continued insight. During his stay in the hos-
pital, coarse tremors developed in the arms and hand, and when he was allowed
to be up, his posture and gait showed the characteristics of paralysis agitans.
The course of his illness was brief, and after six weeks he was discharged
as cured.

Subsequent Course. — A year following his recovery, the patient was again
seen. He was without physical residuals except for a certain slight rigidity
of the upper extremities and a tendency for the hands to take the parkinsonian
position. Mental examination revealed that he talked freely, had good retention
and memory, entertained no abnormal ideas, in fact he made quite a natural
impression.- However, he said that he was now considerably more quiet than
before his illness. His sister and all of his friends mention this to him and
continually urge him to liven up and take more interest in social affairs. This
he thought he was doing. He did not feel depressed nor worried. He took his
usual interest in daily papers.

Although he got back to work one month after leaving the hospital, he
found during the ensuing several months that he was unable to mix with people.
He said, "During the winter I used to hide from people. I was always look-
ing for a chance to be alone." Although shy regarding social affairs, he was
not ambitionless nor indolent. There was no lessened ability to work parallel
to the lessened ability and lessened desire to mix with people. Although he
■could think of nothing definite to cause him concern and even denied feeling
sad, when asked why he was more quiet than before he said, "My mind brings
more worries than it did before." No better explanation of his loss of liveliness
could be drawn from him.

For the period of his illness there wjas no amnesia. The vague fears which
he felt early in the attack did not relate to ideas of dying. Such a thought
did not enter his mind. In fact, he was not at all distressed at being sick.
Touching on his mental state during the course of his illness he said, "I was
so lazy t|^t I didn't want to have nothing on my mind."

Case 5. — Even-tempered. Optimistic. Regular habits. Efficient. Slow
■onset oculo lethargic syndrome; later very severe pseudoparkinsonian syndrome.
General rigidity. Kept given positions. Unresponsive. Stupor. Later euphoria
with uncontrollable laughter. In retrospect, depressed mood during lethargic
and stuporous stage. Though physical residuals (pseudoparkinsonian) are
incapacitating for work, there are no demonstrable mentcU residuals except a
possible abnormal stubbornness. "

History. — H. S., aged 32, violinist, admitted to Bellevue Hospital, Oct. 15,
1919, with a negative family history, was born in Russia, received only a poor
schooling, in all about four classes, but learned to play the violin by which
means he made his living. He came to the United States at the age of 23, and



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over here made a fair living because he was leader of his own small group of
musicians and had plenty of work to do, playing for dances, etc., on the lower
East Side of New York where he lived. He was married and there were two
healthy children.

He had always been steady and regular in habits, never drank, used cigarets
in moderate excess, and had never had any venereal disease.

In make-up, he was even-tempered and good natured, good to his family,
optimistic, never gloomy nor worried. He was not easily angered. He read the
newspapers daily because he liked to keep informed. He inclined to attend
the synagogue regularly, even sometimes twice a week. He was fond of social
affairs, other than card games; always felt well and was not a complaining
type. In 1918, he had influenza for ten days without any complications or
residuals.

Present Illness. — The patient's illness began in September, 1919, with severe
headache, weakness and drowsiness. His head felt as if there were wheels in it.
There was no diplopia at that time and no ocular symptoms later. For three
weeks he was in bed at home. He knew his wife and others, was not confused
regarding time and did not express any peculiar ideas. He was able to walk
to and from the lavatory until the last few days prior to admission to the
hospital. It had also by that time become difficult for him to take food and
almost impossible for him to talk owing to the rigidity of the tongue, lips
and face. Similar rigidity was general throughout the body musculature on
admission.

ExamituUion. — In the hospital, the fever of 101 F. remained for only one
day. The leukocyte count was 12,200, 69 per cent, polymorphonuclears. The
blood pressure was 120 ; the Widal test was negative. Neurologic examination
revealed no defects in the extrinsic ocular movements. The pupils were nor-
mal; the fundi negative; the facies masklike. There was an unwinking, rep-
tilian stare. Marked muscular rigidity was noted in all extremities, and in the
facial muscles, also ir the tongue. Lateral movements of the lower jaw were
impossible. There was a tendency to maintain the arms in given positions.
There was increase in the ligamentous tone; there was no stiffness of the neck.
The Kernig sign was absent. Deep reflexes were obtainable when muscular
relaxation was secured. Plantar reflexes were normal. No demonstrable sen-
sory changes were noted. The blood Wassermann reaction was negative. The
spinal fluid showed 20 cells, a negative Wassermann reaction and the colloidal
gold curve was 1122100000.

Clinical Course. — Four days later there was noted a midbrain tremor, affect-
ing especially the left upper extremity, also a thalamic facial paralysis on
the left.

After thirteen days in the hospital, the parkinsonian tremor was present in
all extremities and still more marked in the left upper extremity. During
approximately the first ten days there was marked mental torpor and drowsi-
ness. This diminished. The facial expression brightened, although the thalamic
weakness persisted. At this time the mood changed and the patient became
euphoric. With this, there was uncontrollable laughter. Other patients noticed
him laughing impulsively for, as they said, "two hours at a time." He felt
happy at this time and the laughing, although he could not stop it at will, was
in accord with his feelings. Joking about it among the patients and things in
general in the ward are believed to account for the length of time it fre-
quently lasted.



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During the period in the hospital when the patient was stuporous he did
not seem to understand questions, but in retrospect he says that he understood
everything and that he was unable to talk because of the rigidity of his tongue,
lips and all his vocal apparatus. The patient was not delirious, did not react
to delusions or hallucinations, and showed no negativism.

When questioned during convalescence, the patient was able to give a good
account of his trip to the hospital and later happenings. He said he "felt
tired and sorry" and "worried about" his illness.

Regarding the maintenance of an imparted position he remembered that
physicians put his arm. in the air, and he kept it there because it was stiff.
Although it was possible to bring it down, it was not. so easy to do so. He
"was glad to bring it down but couldn't easily — it was too stiff."

Subsequent Course. — When seen a year later (October, 1920) he showed a
severe residual parkinsonian syndrome with the right hand and arm in the ,
position assumed in paralysis agitans, variable fine tremors, masklike facies
and an annoying tendency to fall forward in walking.- These features had
entirely precluded his return to violin playing and had kept him from work.

Mentally at that time, his attitude was normal, except for a possible stub-
bornness in refusing all work except violin playing. He had a good interest
in affairs and quite excellent memory. He read newspapers each day and gave
points concerning several matters quite accurately. He was abl^ to repeat
six digits rapidly. His difficulty in performing small tasks in arithmetic was
considered in keeping with his training. * He was not emotional when telling
of his condition and was not unduly anxious.

Case 6. — Good make-up unth slight indication of emotional instability.
Lethargy, general rigidity and unilateral limb pains. Transitory slight con-
fusion and delirium. Next followed prolonged immobile state, masklike face,
mutism and gazing. No catalepsy or negativism^; tearful on stimulation. Vague
fears and anxious ideas, few hallucinations. Recovery unth little amnesia.
Possibly more indications of emotional instability than before illness.

Family History. — T. R., aged 31, freight handler, admitted to Manha'.tan
State Hospital, April 26, 1920, with a family history that was negative tor ' r
vous and mental diseases, was born in Ireland. He was healthy as a child,
received instruction in the common school as far as the fifth reader and was
an average pupil. He did laboring work, was industrious and steady. He
came to the United States seven years ago and has since worked as a freight
and express handler. In disposition, he was said to be even-tempered, friendly
and sociable. He was regarded as rather "tender hearted" and easily moved
to show affection. He drank whisky moderately. He was married three years
ago and had two children, living and well.

In the spring of 1918, he had influenza, was in bed two weeks and recovered
without sequelae. He never had any nervous or mental trouble prior to his
present sickness.

Present Illness. — Early in February, 1920, he was taken sick with fever,
pains in the head, neck, right shoulder and arm. He felt drowsy and "dopey"
and was in bed off and on until his wife gave birth to a baby, February 22.
He then made a great effort to keep up and continue at work. About the mid-
dle of March, however, he gave up and went to bed. He ihen felt -very
sleepy and heavy, and continued to have pains in his right shoulder, arm and
leg. He was weak and shaky. For two or three weeks, he lay in bed almost
immobile; he rarely spoke and had a peculiar blank facial expression. Occa-



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sionally, he would express some vague fears and anxious ideas. He said some-
one w^s after him; he thought people in the hall talked about him but he
could not understand what they said; he imagined he was to be taken away.
A few days before he was sent to the hospital, he was more apprehensive and
uneasy, talked of being killed by some one but did not specify by whom. He
was taken to the psychopathic ward of Bellevue Hospital. He there appeared
very weak, perspired profusely, and most of the time lay very quietly in bed
in a rigid attitude gazing at the ceiling. He did not answer questions, although
he appeared to make some effort at speech by mumbling, and he would under-
stand and obey simple commands such as to show the tongue. There was some
general stiffness when passive motion was attempted but no catalepsy.

Examination. — April 26, 1920, the patient was transferred to the Manhattan
State Hospital. He then had a fever of 102 F. which gradually declined to
normal in five days. The pupils reacted to light and the eye movements were
free. The knee jerks were equally increased. Spinal puncture gave positive
globulin, no cells and a negative Wassermann reaction.

Clinical Course. — For four months following his admission to the state hos-
pital, the patient continued to exhibit a marked reduction in activity, but
without muscular stiffness, resistance or catalepsy. He never drooled saliva,
held his urine or showed other negativistic behavior. He rarely changed his
posture in bed, requiring to be spoon-fed and for a time urinated and defecated
without making any effort to go to the toilet or to let his wants be known.
He did not appear to be drowsy during the day, as he kept his eyes open
most of the time and usually gazed in one direction. The masklike facial
expression was striking. When approached he would, however, give some
attention, as shown by the eye movements, and on various occasions he dis-
played considerable emotion even though he would not speak. For instance,
during his wife's visits, tears would roll down his cheeks and often he would
hold on to the physician's hand and act as if he wanted him to remain. Some-
times he would mumble as if he were trying to say something. On one occa-
sion during the early part of his hospital residence, he answered a few ques-
tions after much urging. He seemed then to be rather perplexed and unclear
as to the situation. He was not certain whether he was in a hospital or not,
said it was 1916 or 1920, could not tell how he came to the hospital or how long
he had been here. He spoke of hearing Jewish and Italian peo^e talking, also
of hearing his wife's voice. Once in a confused way he spoke of his citizen-
ship papers being on an empty chair by the bed. (He .had been naturalized
just before his illness. After recovery he said he imagined if he were known
to be a citizen he would be better treated.)

During August, 1920, the patient began slowly and gradually to emerge from
his inactive state. Nov. 20, 1920, he had apparently recovered and was ready
to be discharged.

Subsequent Course. — He was bright and alert and capable of doing consid-
erable work without fatigue. He had excellent insight and repeated tests failed
to show any impairment of his general memory, retention, attention or men-
tal capacity. His interests were keen, he was anxious to return to his family
and his emotional reactions were adequate and stable with perhaps one excep-
tion: when talking of his wife and children, the separation from whom he
felt very much, his eyes were apt to fill with tears. He said it was his nature
to be affected easily and this was confirmed by his wife (see personal history).



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On reviewing his illness with him it did not appear that there was any
definite period of amnesia which could be defined. He recalled very well all
of his movements and most of his symptoms.

He mentioned among the early symptoms a heavy, sleepy feeling and pains
and stiffness, especially on the right side of the head and body (shoulder, arm
and leg). Later he felt vaguely afraid that something would happen to him,
that he would be taken away, perhaps killed. Hallucinations were infrequent,
occasionally he heard remarks which he thought referred to him. Once he
imagined he heard his brother speak, saying, "Oh, Terry, I dread the operation
table." On another occasion he thought he saw his wife outside walking across
the lawn (illusion?). He recalled that he lay still and inactive, gazing and
not responding to questions. His explanation for this conduct was that he
felt extremely weak and did not care to move or exert himself. He also
said that he was vaguely fearful of attendants and other patients, thought he
was disliked and thought it was best to keep quiet. He thought he realized
where he was fairly soon after he came to the hospital, but he could not
keep track of time. He could not give any reason for his failure to speak
except that he was timid and weak, as he put it, "so sick and deadlike that
I didn't care for speaking." As to his mental content during the stupor (aside
from the occasional fears), he said, "There was really nothing on my mind at
that time." He seemed to have felt very dull and without initiative, he was in
a negative, colorless, emotional state unless he was stimulated in some way.
then he was apt to feel anxious or worried. As he put it, "I was careless-like
(indifferent) until my wife or my friend came— then I would worry about my
family." (He was often tearful during visits.) In a somewhat similar way,
if he had to get up or was taken to the toilet, he would become anxious and
feel vaguely fearful under this situation. As he improved he worried a great
deal about his family and his circumstances.

Case 7. — Good make-up. Efficient. Sociable. Moderately alcoholic. Ten-
dency to worry. Myelo-encephalitis, cervical localisation with lower motor
neuron signs. Also oculomotor symptoms and pseudo parkinsonian develop-
ment. At onset, delirious episode. Lethargic course over eight weeks followed
by depression, the latter persisting after five months in moderate nonincapaci-
tating form with fluctuations in intensity.

Family History. — ^J. B., aged 35, a structural iron-worker, was admitted to
Bellevue Hospital, Feb. 23, 1920, with very little information. There was no
known mental or nervous disease. The patient was born in Denmark and had had
only a few years of schooling. Having been made an orphan, he went, to work
at the age of 10 yeafs variously as a farmhand and woodsman. Later, after
emigrating to the United States, he learned the structural iron-worker's trade
and in this made a good living.

Twenty years ago he had typhoid fever and subsequently gonorrhea. Syph-
ilis was denied by name and symptom. He was married and there had been
one healthy child. Though he drank considerably, he asserted that he could
count on one hand the times he had been intoxicated. He was inclined to
rather excessive venery, yet ceased all promiscuity on marriage. His physical
strength was above the average and he described himself as "a hearty eater
and a heavy worker."

He always had the reputation of being a jolly fellow — one inclined to banter
on festive occasions, but he was a hard and steady worker. As a child, he
was taught religious ideas scrupulously (Lutheran), and though he never at
any time acquired the habit of church attendance, he always retained a religious



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feeling about things so that he still each night said the prayers which he
learned in childhood. Though he denied that he was ever subject to depressed
periods, he told how he was always more inclined to worry about things than
his wife. For example, when he was in good health and had no reason to fear
imemployment, he would always feel uneasy after finishing one job until he
secured another. As regards principles and character, he was a man of more
than ordinary steadiness and reliability, largely owing to happiness of his
domestic life. He led a tranquil, contented existence in spite of his hazardous
occupation.

Present Illness. — Early in February, 1920, he began to complain of pains in
his arms and shoulders, the pain being more severe on movement and pressure.
After this had been present for about a week, he was compelled to quit work.
At this time there was a beginning weakness of the arms. There was diplopia,
then for a time some delusional ideas (see below).

Examination. — On Feb. 23, 1920, he entered Bellevuc Hospital and showed
the following neurologic status: The pupils were small and irregular, but
reacted to light and were in accommodation. The fundi were normal. Diplopia
had developed ten days before. Eye movement was well carried out; there
were nystagmoid twitchings in the external lateral position. There was a sug-
gestion of right facial weakness, tremor of the eyelids and tongue. The face
was flushed and masklike. There was great weakness in both arms. The
extensors were more affected than the flexors. There was weakness of the



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