A Visit to the Admitting Office 1916

Dr Smith at the Southern State Hospital for the Insane looks out into the admitting office waiting room on a pleasant Monday morning, May 15, 1916. A quiet day so far, only three patients, two sitting fairly quietly with their groups of attendants, probably family members, and one woman with a man who might be her husband. This one keeps getting up and pacing for a few seconds, then sitting back down. Better get started, Dr. Smith says to himself, there will probably be more, and worse, later today. He calls his first patient, Mrs. McCreedy. She comes into the examining office, accompanied by her companion, who does indeed turn out to be her husband.

Mrs McCreedy and her husband are from the country and clearly not very prosperous. They work as sharecroppers and, as Mr. McCreedy relates, they have little money for food and must keep all their land in their cash crop, cotton, so they can’t grow any vegetables. They mostly eat hominy grits, molasses, biscuits, fat back and sometimes some collard greens. Mr. McCreedy tells Dr. Smith that over the past year or so his wife has become forgetful, snappish, anxious, and does not sleep well. Her stomach is upset and she always has the “runs.” Lately she seems to be unable to be still and forgets basic things, like the names of their children. Mrs. McCreedy is distracted and restless during the interview, but she nods when Dr Smith asks her if this is true.

Dr Smith then examines Mrs. McCreedy. She is fairly dark skinned but he can still see that her arms, upper chest and hands, the areas that are out in the sun, are rough and reddened with peeling skin. Her tongue is red and swollen looking and her heart sounds indicate that her heart is enlarged. She recoils when he tries to shine a light in her eyes to check her pupils

Obviously, this is a case of ___(1)___ Dr Smith tells Mr. McCreedy.

Patient number two, Mr. Jordan, is a middle aged man accompanied by his daughter and son-in-law. When questioned he tells Dr. Smith an elaborate story about how the devil is causing people to follow him around and try to poison him.  His daughter tells Dr. Smith that her father is 52 years old, and never acted like this before. He lives with her and is a teetotaler and doesn’t use any marijuana, cocaine or heroin. Upon questioning Mr. Jordan admits he has been feeling really weak, nauseous and constipated lately, which he attributes to the poisoning.

When Dr. Smith examines Mr. Jordan he finds ulcerated sores scattered all over his body.

“Has he been taking anything for his nerves?” he asks the daughter.

“Why, yes,” she answers, somewhat surprised by the question, “But nothing strong. Just this thing called Nervine.”

“Well this is a problem we can fix,” Dr Smith says, “This is a case of __(2)___ and we’ll have your father feeling much better in a few weeks.

Time of the third patient. “Mr. Wilson,” Dr. Smith calls out and an elderly man slowly gets up. As he walks across the room, the man lifts his knee high with each step, his ankle flopping, and then slams his leg down on the floor. In this way he lurches into the examining room accompanied by his wife and two sons. His family relates that their husband and father is “not himself” lately. He obviously has difficulty walking, but he is also forgetful, loses things, and has been accusing them of plotting to kill him so they can inherit his money. Mr. Wilson just mutters and states that his problem is pain; severe headaches, and shooting pains running “up and down my body.”

Dr Smith notes the gait problem on examination and also that Mr. Wilson’s pupils get smaller when he moves his finger closer to Mr. Wilson’s nose, but not when he shines a light in them.

Well, this is awkward, thinks Dr. Smith. There’s no doubt about what Mr. Wilson has, ___(3)___, but it might be a shock to the family. Perhaps if I used medical terminology?

Dr Smith was able to be so sure of his diagnoses because these three conditions might have had up almost half of his admissions at the state hospital. Times have changed however and today’s psychiatric illness prevalences are quite different. So how do you do? Answers are below.

1. Pellegra

Pellegra is niacin deficiency. In the first third of the twentieth century pellagra was endemic in the American South, as well as other places. In fact, there are places in the world even today where there is still pellagra, however, improved diet has eliminated it in the developed world unless someone has an extreme lifestyle, e.g. drinking and not eating anything.

Symptoms are summed up by the “three d’s,” diarrhea, dermatitis and dementia. Some people add a fourth “d,” death. If you don’t get your niacin, you’ll die in about 4-5 years. People with pellagra were also noted to be more excitable, aggressive and argumentative, which certainly didn’t help.

The symptoms above, and probably knowing that the person was poor and rural would have made the diagnosis clear to the psychiatrist of the day. Unfortunately, in 1916 people hadn’t quite learned that pellagra was a dietary deficiency, so whether or not Mrs. McCreedy got better at the hospital would depend on how good the food happened to be, rather than any prescribed treatment.

2.. Bromism

Once upon a time, according to that great source of medical knowledge, Wikipedia, 5-10% of all psychiatric admissions.were due to bromism, or bromide toxicity It certainly seems possible, as compounds such as Nervine, which contained bromides.

 (see http://www.youandmemagazine.com/articles/over-the-counter-medicines-of-t...) were widely available. The old slang expression to refer to something as a “bromide” comes from the use of these sedatives Calling a book or a play a bromide meant that it was so boring it would put you right to sleep.

Symptoms include rashes of various kinds and psychiatric and/or neurological symptoms. These neurological and psychiatric symptoms are variable. They include restlessness, irritability, ataxia, confusion, hallucinations, psychosis, weakness, stupor and even coma. Treatment would basically be stopping using bromides so the toxic levels would drop. The author Evelyn Waugh had a bout of bromism late in life and wrote about developing quite a paranoid psychosis.

Our doctor of one hundred years ago would have suspected bromism by getting a history of using a sedative, and by seeing characteristic skin changes.

3. Syphilis

We still have syphilis of course. But we don’t have it nearly as much as people did around the turn of the twentieth century. According to one closely reasoned study of syphilis figures, http://shm.oxfordjournals.org/content/27/3/508 , the prevalence of syphilis in men in their thirties in England in 1911-12 was about 8%. If the USA had a similar prevalence to day for it’s whole population, that would be about 2.6 million people. Instead, the CDC reports there were 20,000 cases of primary and secondary syphilis reported in 2014.

Psychiatrically, it’s not primary and secondary that are the problem, but tertiary syphilis, which starts showing up about four to twenty-five years after infection. When syphilis attacks the nervous system it is known as neurosyphilis. One hundred years ago doctors would talk of general paresis, general paralysis of the insane or paralytic dementia, but these all meant syphilis. Syphilis was called the “great imitator” because it could present in so many ways, but the physician of one hundred years ago was always on the lookout. Perhaps the doctor would see that the patient’s pupils no longer reacted to a light being shown in them, or see tabes dorsalis. “Tabes” occurs when syphilis attacks the spinal cord. It destroys proprioception so the patient tends to lift his knees up with his feet flopping and slam them down on the floor to walk. But mostly the admitting doctor would know it was syphilis because it was just so darned common—perhaps up to 25% of all psychiatric hospital admissions were for neurosyphilis.