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CHOICE OF MATERIAL. Two thousand cases admitted consecutively to the Psychopathic Hospital in Boston were reviewed with respect to the age at onset, and 345 were found to fall between the years of forty and fiftynine. The following groups were excluded from this number on the ground that they had no epochal significance.

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Cases. 1. Continuous or periodic disorder beginning before 40

106 2. Diseases with known exogenous causes...... 3. Senile and organic cases (including arteriosclerotic psychoses)

31 4. Unclassified cases beginning before 40, pa

tients with meager history or those not
insane

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239

69.3 The remaining 106 cases, 30.7 per cent of those of the 5th and 6th decades, form the material of the present study.

DIAGNOSTIC SUMMARY OF CASES. According to final diagnosis at the hospital the 106 cases fall into 25 groups. These may be placed in larger classes as follows: Manic-depressive psychosis

38 Dementia præcox, paraphrenia and paranoic condition..., 27 Unclassified, “no diagnosis” and indeterminate diagnosis.... 28 Presenile, involutional and unclassified depression...

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Thus 41 cases or about 38 per cent of the selected group are not definitely classified. Another characteristic of the 106 cases appears if we compare them according to the proportion of the sexes with the admissions during the 5th and 6th decades of the 6000 cases.

Males.

Females.

No. Per cent. No. Per cent. Selected cases

30

28.3 76 71.7 Cases admitted in 5th and 6th decade, 6000 P. H. cases...

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45.1 Six thousand cases, all ages..

54.9

3125 52.I

2875 47.9

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In the selected" functional" group 71.7 per cent are females. Of all cases in a series of 6000 admitted between the ages of 40 and 59, 45.I per cent are females. The latter proportion is very nearly the same as the percentage of females (47.9 per cent) in the entire series of 6000, disregarding age.

STUDY OF SPECIAL GROUPS. About two-thirds of the 106 cases could be placed with more or less certainty under the captions of manic-depressive psychosis and dementia præcox. The remaining third did not readily admit of classification. The considerations upon which these distinctions were made are mentioned in connection with the discussion of the separate groups.

MANIC-DEPRESSIVE PSYCHOSIS.

Thirty-eight cases showed the usual features of manic-depressive psychosis, and were so called at the Psychopathic Hospital and subsequent hospitals if there were any. The maniacal cases will be treated separately. The depressed cases are subdivided along the lines of motility—that is (1) as retarded, (2) as agitated, (3) as both, and (4) as showing no particular motility disorder. This division is made largely for the purpose of bringing into view the agitated depressions which have been looked upon as peculiarly associated with the involutional years.

In all the manic-depressive cases, family history of mental disease is mentioned in only five cases (362, 1917,966, 1901, 1863), the relatives being, respectively: sister; father; brother and sister; aunt and two uncles ; daughter, mother and sister.

Mention is made of menopause in nine cases, as follows:
Two (1173, 1676). Ten years before onset.
One (1241). Five years before onset.
One (388). Three years before onset.
Five (1192, 1138, 178, 1777, 1768). Onset during menopause.
In seven cases there was evidence of physical disease:
One (553). Irregular pupils, palpable arteries (W. R. & S. F. Neg.).
Two (87, 1834). Scar of hysterectomy (1834, recent).
One (882). Vesico-vaginal fistula.
One (517). Carcinoma of penis.

Manic Phase.—There were eight cases in this class, five female and three male. Five had passed through previous attacks, but had none before 40. Subsequent history of six was obtained. Two were discharged recovered, two improved and two unimproved. Two were still in a state hospital four and five years later, one improved and one unimproved. These cases were all described as euphoric, hyperkinetic and distractible.

Manic-Depressed with Retardation—This group comprised 14 cases, six males and eight females. In four there had been previous attacks, and in one a subsequent attack is reported. There is no record of the later condition of eight. Three of these were discharged from the Psychopathic Hospital improved and two unimproved. Of the remaining six, one is reported through the out-patient department two years later to be “ nervous and tearful.” Two were discharged from other hospitals recovered, one improved, one died of lobar-pneumonia, and one was in the hospital four years later unimproved.

Five of the patients expressed no delusions. One (239) had a feeling that some indefinite calamity impended, and one (362) repeated monotonously, “What shall we do when cold weather comes." Three had somatic ideas: (1842) "intestines stopped up and everything moving about inside the body," (87) “ feels bad all over,” (1901) “ an awful impression, a dead feeling about heart." There were persecutory delusions in three; in one, coupled with self-reproach. In one the dominant feeling was suspicion, and in the third there was a definite reaction of aversion to the men of the family. In two the dominant feeling was one of selfreproach, one (1241) had ill-treated her sister, and one (1777) felt she was pregnant by the son of a friend. Three threatened or attempted suicide. Hallucinations (flashes of light) were described in only one case aside from the general somatic feelings mentioned above.

Manic-Depressive, Depression with Agitation—This group consists of seven females and one male. None of the cases had had previous attacks, but three had recurrences. Three were improved and one was unimproved upon discharge from the Psychopathic Hospital. Of the five with after-history, two were still in hospital four years later and were reported improved, and one was recovering from a third attack. Two had been discharged, one after a year as improved and one after two years as unimproved.

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Delusions were present in all. In one there was a feeling that "something dreadful would happen." The ideas were self-condemnatory in four (92, 154, 882, 1134). In one of these (882) there was a real basis in the odor from a vesico-vaginal fistula. In four the patient was the object of persecution. Hallucinations are described in two cases: "little voices inside " (882), and “ people talking about her character " (1768). General somatic ideas were found in one case (1956) in which there was a complaint of many pains, for which no cause could be discovered.

Manic-Depressive with Both Agitation and Retardation.-In one case (1676), there was usually retardation passing over into agitation at times. This patient, a female aged 55, was suicidal and self-condemnatory. In a second case (350), a female aged 53, speech was retarded although the general behavior was agitated. This patient insisted that her "bowels would not move." She died of broncho-pneumonia while in the Psychopathic Hospital.

Manic-Depressive without Conduct Disorder.-There were six cases, three male and three female, in which motility was not a prominent feature. Two (722, 178) had passed through previous attacks, and of these one (178) had a subsequent attack. All the cases had well-marked delusions. Three had somatic delusions, “evil spirit in belly" (553), “ face not right, frozen stiff, cannot get heat into body (388). " Bowels tied up, pins and needles in flesh at night " (722). One of these cases (722) was complicated by alcoholism. The patient heard voices from his stomach, thought he had improper relation with men, and possibly had some degree of peripheral neuritis (pins and needles). The delusions of the other three cases were of the persecutory type, in one case (963) in the future tense. One female (178) heard people outside on street talking about her.

One patient (517) had carcinoma of the penis, of which he shortly died. One (178) recovered from this attack and also from a subsequent attack. A third (722) was discharged in seven months, "much improved.” One (553) was in hospital three years later, unimproved; of the remaining two cases (963, 388) there is no later account.

Discussion.—The principal facts available about the manicdepressive cases are shown in Tables II and III. The outlook, it appears, is rather favorable, in that only five out of the 22 with

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after-history were not improved or recovered. An important characteristic of the manic-depressive psychosis is repetition of attacks. Although the longest after-history is less than five years, there was account of more than one attack in 16 out of the 38 cases. The proportion would doubtless be greater if the cases were followed longer. Recurrence is of especial interest in the agitated depressions, because of the association between this type of reaction and a poor prognosis suggested in Kraepelin's treatment of the subject in his latest edition. Although he abolishes the picture of involutional melancholia in favor of a mixed phase of the manic-depressive psychoses, it is noticeable that the four or five "presenile" groups tentatively proposed by him are all characterized by anxious depressions. In our groups of agitated depressions, there is subsequent history in only five, but in three of these there were repeated attacks. In number the agitated depressions were not more than 10 cases out of 38. So far as the present group is concerned, therefore, agitated depressions are not the predominant form of manic-depressive psychoses in the presenium, nor do they seem of bad prognosis. On the other hand, they tend to recovery and recurrence.

In the table of delusions (Table III) no attempt has been made at a consistent classification. There may be some question whether the two classes mentioned last should be called delusions at all. One may call them falsification of memory and apprehension, but there does not seem to be any adequate reason for distinguishing them from delusions merely because they are not in the present tense. Six cases out of the 38 are stated to have no delusions, but as all but one of these are retarded cases, it is likely that some at least have merely failed to express their delusions. According to the table no type of delusion is much more frequent than others.

Only six of the delusions mentioned are evidently absurd; these

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are:

1888. Is God, king of China, Pope.
1754. Family is Holy Family.
269. Sun is heaven.
388. Face isn't right-is frozen stiff, can't get heat into body.
553. Evil spirit in belly.

1842. Everything wrong inside body. Is chased by six spiders by night and six spiders by day.

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