Three of these cases had more than one attack.

The cases which at last report were still in hospital, but improved, had been under observation for the following periods:

The duration of the cases which at last report were still in hospitals unimproved is as follows:

Only one of these cases had recovered from a previous attack. The condition upon discharge from the Psychopathic Hospital of cases upon which there is no later report is as follows:

Recovered
Improved
Unimproved

Not mentioned

4

12

14

12

In estimating the value of the reports of the later condition of the patients, the length of the period of observation must be considered. The group "in hospital improved" is much more informative in a sinister sense than is the "discharged improved " group in a favorable sense, not only because of the obvious fact that they were not well enough for discharge, but also because of the much longer average hospital residence of the former group. (The averages are, roughly: "in hospital improved," 4.5 years, discharged improved," 1.3 years.) In fact it would probably be better for practical purposes to separate the cases which had been three years or more in hospital and consider them as unfavorable. This would give 25 cases out of the "still in hospital" classes to be so considered. The value of the 10" recovered" cases is minified somewhat by the fact that four of these have had

66

more than one attack, so that the recovery" refers to the attack, but does not relieve from expectancy of other attacks.

It would give a better idea of probabilities to state the cases with repeated attacks separately. We should have then:

I. A statistical review of clinical data in certain cases with onset between 40 and 59 is presented. Cases with gross brain disease or known exogenous causal factors are excluded.

2. The cases are drawn from Psychopathic Hospital admissions which have been shown to include about 20 per cent of cases which would not reach a state hospital for insane. The group therefore is a fair collection of mental disorders as they actually occur in the community.

3. The use of the age-period as viewpoint is an advantage in method; in that, it (1) emphasizes epochal characteristics, (2) is inclusive, and (3) eliminates minor errors in the statement of ages.

4. A previous study of 6000 consecutive admissions to the Boston Psychopathic Hospital has shown that (1) in the 5th and 6th decades, no particular diagnostic group is numerically predominant; and, that (2) within these decades "undiagnosed " and "unclassified" forms are twice as frequent as in the 6000 cases without respect to age.

5. In the present study 2000 consecutive admissions to the Boston Psychopathic Hospital have been reviewed. Three hundred and forty-five were between 40 and 59 years. The following classes were excluded: Continuous or periodic disorder beginning before 40; diseases with known exogenous cause (alcohol, syphilis, etc.); senile and organic cases. The residue of 106 cases forms the material of the paper.

6. The data utilized included the usual personal facts and physical and psychiatric examinations from the case records, the diagnosis, and in about half the cases a report, obtained from

various Massachusetts state hospitals, of subsequent course and later diagnosis after from one to five years.

7. A striking feature of the special group as defined in paragraph 5 is that nearly 72 per cent are females. Of all cases in a series of 6000 admitted beween 40 and 59 (without regard to diagnosis) 45 per cent are females.

8. Sixty-five of the 106 cases could be placed definitely into the two groups of manic-depressive psychosis and dementia præcox. These diagnoses depend upon: (1) The opinions of the Psychopathic Hospital staff, which in a large proportion were (2) confirmed by the staff of the hospital to which many of the cases were later assigned, and (3) upon review of the cases in the light of all the obtainable facts. In a few instances review of the cases led to a change in the earlier diagnoses. Forty-one cases were not easily classified.

9. Of the 38 manic-depressive cases with onset after 40, 10 were of the manic type and 28 were depressed. The "agitated depressions" numbered 10 cases.

IO. There was history of more than one attack in 16 out of the 38 manic-depressive cases. (No cases were included in this study if the first attack occurred before 40.)

II. Twenty-two of the manic-depressive cases were followed from one to five years after observation at the Psychopathic Hospital. Only five had neither recovered nor improved.

12. The diagnosis of dementia præcox was made in 27 out of the 106 cases.

13. The subsequent history of 19 dementia præcox cases was followed. Ten were in hospitals unimproved four years later, one died unimproved two years later, three were reported unimproved six months later. Four were reported to be improved, and one case was said to be recovered after the mental disorder had lasted over six years.

The eight dementia præcox cases without subsequent history were all unimproved upon discharge after duration of from six months to 2 years.

14. In 41 cases the diagnosis was not clear, not confirmed by a second hospital, or upon review the cases appeared too anomalous to allow classification under the usual groups.

15. These 41 cases are reviewed with respect to a prognosis, on the basis of the 25 cases in which subsequent history is known. Five cases died, four recovered, seven improved, and nine remained unimproved.

16. In the five cases which died there was a possible relation between the psychosis and the cause of death in three.

17. The four cases which recovered showed no features at the Psychopathic Hospital by which the favorable outcome could have been predicted.

18. In the entire group of 106 cases information as to the use of alcohol is given in 38. Three drank heavily and 14 moderately. Alcohol seemed in no case to have any noticeable effect upon the psychosis.

19. The blood serum was positive by the Wassermann reaction in three cases and doubtful in one case out of 74 tested. Cerebrospinal fluid was "suggestive" in two cases and clearly positive in none, out of 13 tested. The cerebrospinal fluid in two cases with positive sera was negative. The third was not tested.

20. In 25 cases out of the 106 there were obvious somatic diseases and defects. In eight cases these were reflected in the psychotic picture, and in 17 there was no evident connection.

21. Delusions were expressed in 98 of the 106 cases. Most of the eight exceptions were retarded cases. Persecutory delusions were expressed 78 times, somatic 21 times, self-condemnatory 16 times and jealousy, grandeur, etc., a few times.

22. Delusions of negation were found in one case, and delusions of unreality in three.

23. Auditory hallucinations were described in about two thirds of the dementia præcox cases, one-sixth of the manic-depressive cases and one third of the unclassified groups.

24. There is a positive correlation between auditory hallucinations and allopsychic delusions in two definite groups of cases: (1) Depressed cases without motility disorder, and (2) cases in which the emotional state did not correspond to the content of the delusions.

25. As to emotional quality, 10 cases were elated, 68 were depressed, 15 were said to be "normal," six were "apathetic," two were variable and four passed from initial depression to final apathy or elation.

26. The expressed mental content of 102 out of the 106 cases

was of an unpleasant character, ranging from the most terrible delusions to hypochondriacal ideas.

27. Of the 10 cases which were continuously euphoric, only two were free from ideas of an unpleasant quality.

28. The emotional quality of the ideas and the emotional expression were consistent in 69 cases and inconsistent in 36.

29. Katatonic symptoms were present in eight cases or 7 per cent. One of these is said to have recovered, one died, one was lost sight of and the remainder were still in hospitals several years later.

30. The outcome on the 64 cases in which reports from subsequent hospitals are available is as follows:

31. A large proportion of the 36 per cent upon which there is no later hospital history belongs to the non-institutional class reached especially by a psychopathic hospital. The condition on discharge is stated in 30 out of the 42 cases of this group. Sixty per cent were improved or recovered.

CONCLUSIONS.

A review of psychoses from psychopathic hospital material, which arise in the 5th and 6th decades and are not due to gross brain disease nor to exogenous factors permits the following conclusions:

1. About 60 per cent can be classified as manic-depressive or as dementia præcox.

2. Cases with agitated depression, delusions of unreality and of negation, and with katatonic features are relatively uncommon. 3. Delusions of unpleasant content are characteristic and are almost invariably present.

4. In a large proportion (34 per cent) the prevailing mood is inconsistent with the ideas expressed.

5. If recurrent cases are counted as favorable the prognosis is good in about 25 per cent.

Excluding recurrent cases, an absolute recovery was reported in 10 per cent of 64 cases with later history.