TABLE III. THE CHANGES IN DIAGNOSIS BETWEEN PSYCHOPATHIC AND STATE HOSPITALS. The numbers at the tops of the columns correspond to the numbers assigned in the left-hand column to the Psychopathic Hospital diagnoses. Other Hospitals Diagnoses. 18. Organic Dementia 2 20. Involution Melancholia Senile Delusional Psychosis. Total I I 419 183 63 36 12 12 19 12 19 7 7 14 1 16 0 6 1 2 6 1 2 1 A psychopathic "luetic paranoid" is called "G. P. + paranoid D. P." 2 Called "chronic alcoholic psychosis" at psychopathic. 3 Including three unclassed paranoid, one paraphrenia and two paranoia Psychopathic diagnoses. also high, as in the acute alcoholic psychoses and in the arteriosclerotics. These figures, however, are less valuable because of the small number of cases concerned, but perhaps indicate an overstressing of certain symptoms or symptom-complexes in the diagnosis of these conditions. The data presented in these tables are most conveniently discussed according to the psychiatric groups involved. The points of major interest are found in the cases with change in diagnosis. Accordingly, the greater stress is laid on these. In each case with recorded error, I have analyzed the Psychopathic Hospital record and have based a personal opinion as to diagnosis on that. Where ever possible, I have also either seen the patient or the record from the other institution. This, however, has only been feasible with those patients committed to the Boston State Hospital, representing less than half of the number of errors. I have tried to make an impartial analysis and an unbiased criticism in these cases, with the aim of locating the causes for error if possible. Group I.-Dementia Præcox: This diagnosis, made 183 times at the Psychopathic, was concurred with in 155 cases and disagreed with in 28. This amounts to an error in 14.8 per cent of cases well below the error previously recorded. In 28 addi- . tional cases another Psychopathic diagnosis was changed to dementia præcox. So, if we incorrectly call 15 per cent of cases dementia præcox, and miss 15 per cent, our error becomes rather high. Of course the last error is somewhat less serious than the first, since the chances are that a better prognosis was given with a non-dementia-præcox diagnosis. Of the 28" errors," four have been left "unclassed" by the institution to which they were sent, leaving 24 cases in which the diagnosis seemed erroneous. Of these, 14 are called manic-depressive and two are in hospital "unimproved "; two in hospital" improved "; one was discharged "improved" and nine were discharged "recovered." It may be noted that one case was discharged as a recovered manic-depressive, only to be returned to the institution when a diagnosis of dementia præcox was made. This is, of course, not counted as an error. In six cases the first diagnosis returned from the other institution was something other than dementia præcox, usually manic-depressive, but on second or third inquiry the diagnosis was changed to dementia præcox. These cases again are not counted as errors. It is possible that of the four cases now in hospital, a few may yet be called dementia præcox. In examining our records on these cases, I find that in three the record seems to me typical for manic-depressive, yet a diagnosis of dementia præcox was made. So far as I can see the misleading symptoms do not appear in the record, however clearly they may have appeared in the patient. In two additional cases I cannot form an opinion from our records, as they do not give a sufficiently clear analysis of the case. Neither case was hallucinated, but both were called "indifferent." In two cases I should judge from the history and examination that neither diagnosis was entirely correct, since one case was post-puerperal and one post-operative. The post-partum case, in particular, seems to be one of the toxic exhaustion cases with recovery. The other case presented ideas of reference for a year before the sudden onset of an excited, hallucinated, deluded state following etherization. Here, the confusion and hallucinations, with later recovery, point more to a toxic psychosis than to dementia præcox or manic-depressive. The remaining seven cases are of some interest and may be briefly abstracted: CASE 1.-A man, age 44, first attack of mental trouble. Always rather seclusive, he suddenly became destructive, with ideas of electricity, chok ing, visual and olfactory hallucinations. He was depressed, emotional, self-accusatory, had many somatic and sex ideas, ideas of influence and hallucinations for several days. Remained oriented. Except for the hallucinosis he seemed to be a case of manic-depressive. We called him dementia præcox. Six weeks later he had been discharged "recovered.” Here the hallucinatory episode was allowed too much weight in the diagnosis. CASE 2.-This unusual case is so complex that I am not satisfied that either diagnosis is correct. In 1913 he was committed, a diagnosis of manic-depressive made and he was discharged "recovered." In 1915 he was at this hospital; provisional diagnosis-dementia præcox, determined— delirium tremens. In 1916 he was twice here with a diagnosis of acute alcoholic hallucinosis. In November, 1916, he was admitted for the third time that year. He had many fantastic delusions and numerous hallucinations. At our staff meeting, five preferred dementia præcox to manicdepressive; two, manic-depressive; three, alcoholic psychosis; two, unclassified. Committed to another hospital, a diagnosis of manic-depressive was made and he was discharged "recovered." His drinking may have been due to his manic-depressive attack, but it seems that his psychosis was markedly colored by the alcohol. CASE 3-At 39 this woman had an attack in which she was violent, fearful, self-accusatory and called the dead. This lasted for four months. At 40 she had a similar attack of two weeks' duration; again at 42. At 43 she had an attack of four months' duration, this time influenced by alcohol. She was described as normal between attacks. At 44 she was admitted with auditory and visual hallucinations and ideas of electrical influence. There was no intelligence defect. She was indifferent; at first disturbed, then quiet, inaccessible, mute, resistive and had to be tube fed. During a month this condition continued. After transfer she was discharged as recovered from a manic-depressive attack. If we grant that the observations were correct, and there was no history of alcohol, then our diagnosis was symptomatically correct; although the history would indicate a good prognosis for the attack. CASE 4.-The mother of this girl developed a paranoid psychosis at about 55. The patient was disappointed in love; then became suspicious, deluded and worried. She became hallucinated, with conduct disorder based on this. She was frightened, agitated, depressed, resistive, hallucinated, suspicious, mute, deluded. She was impulsive, at times excited. This continued through her stay of two weeks. After transfer she was discharged as a recovered manic-depressive. With the exception of the rather normal emotional response to the ideas and hallucinations, our diagnosis would seem to be symptomatically correct, but not verified by outcome. CASE 5.-An interesting case of "late katatonia" occurring in a man of 50, with mental changes for a year and a previous attack with hallucinations. He was hallucinated and showed cerea flexibilitas, with later recovery. CASE 6. In this man the question of manic-depressive-mixed might be raised. He had gradually changed through three years and when seen at 38 was indifferent, irritable, deluded, hallucinated, impulsive, selfaccusatory and somewhat depressed. In about three months was discharged "improved" and is now recorded as "recovered." CASE 7. This patient at 29 had an attack in which no hallucinations were demonstrable, but she was disturbed and later mute and resistive. She continued to show many queer signs but has now a "well-connected depression in which there seems to be nothing schizophrenic." Hence, she is regarded as a case of manic-depressive. The next important group in which the diagnosis was changed is the group of four cases called "not psychotic." Two of these were called " constitutional inferiority and two were called feeble-minded." There is no doubt of this groundwork for the mental state in all four cases, but the symptom analysis of the four certainly shows a pathological mental state hardly to be explained by just this diagnosis. I am not arguing that they were necessarily cases of dementia præcox, but that there was something added. That the committing physicians who visit this hospital are very cautious about committing cases on such grounds alone is an additional point in favor of the view that there was a psychotic state. At all events, it is perfectly clear that episodes of various types occur in such patients, but it is not perfectly clear whether they are always a part of the original state or represent a new process. One case in particular, studied by us for more than a month and twice presented at staff meeting, was called an imbecile at the hospital to which he went, although because of agrammatisms, neologisms and what might be called neograms and certain other schizophrenic features, we had made a diagnosis of dementia præcox which evidently went back for a considerable distance into his youth. There was a possibility of an organic condition. Accordingly, one would hardly be satisfied with the simple diagnosis of imbecility in a complex case of this type. One case was called delirium tremens, but is still in the hospital a year and a half after commitment, where he is regarded as improved and is working steadily in the kitchen. If it were really a simple case of delirium tremens one would hardly expect that he would spend a year in a hospital. Our record says there is no alcoholic history, that he was apathetic, had ideas of persecution |