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and somatic delusions. He was not at any time confused. All of these are points against the diagnosis of delirium tremens.
One case which we called dementia præcox with senile changes was called senile dementia. He was 68, had been at Worcester at 18, at the Boston State Hospital at 30 and in some other asylum at 40. For many years, at least 12, he had been foolish, had ideas of persecution, confusion of recent memory, was pleasant, quiet and there were probably auditory hallucinations. The correct diagnosis would depend upon the accuracy of the history of changes for many years.
Two cases called by us paranoid dementia præcox were called unclassified paranoid condition. For the discussion of the difficulties in the way of diagnosis in the paranoid group, see below under “Unclassified Paranoids."
One case was called a toxic exhaustion psychosis from morphine and this diagnosis seems to have been correct, although we got no history of any morphine use.
One case was a post-puerperal case occurring in a negro girl, but with all the characteristics of dementia præcox. However, the institution to which she was sent made a diagnosis of psychosis plus feeble-mindedness and regarded her not as deteriorated but as having been originally of low level. Of course, the diagnosis psychosis plus feeble-mindedness is really equivalent to “undiagnosed” or “unclassified,” since it does not attempt to state the type of psychosis present.
Group II.—Manic-Depressive: In this group there were proportionally many more changes than in the dementia præcox group. Our diagnosis was changed in 18, or 30 per cent of the group. In addition, 21 cases called something else by us were finally diagnosed manic-depressive by the other institutions.
The most interesting change is that from manic-depressive to dementia præcox, made in 11 cases. Two cases were discharged from the hospital making the diagnosis dementia præcox, as “” "recovered"; one was discharged as “improved.” In all three cases the history of previous attacks or the examination here indicates manic-depressive to me.
One case has died and our record is to me clearly that of a paranoid dementia præcox and not manic-depressive as we diagnosed it.
The other seven cases remain in hospital“ unimproved.” Of these, one was called by us “chronic mania,” which is probably really dementia præcox with long-continued excitement. Three cases I should call dementia præcox from reading the Psychopathic Hospital record. One case has an involution psychosis with uncertain features. One case is clearly a manic-depressive with three attacks, a complete recovery between each, and typical symptoms of manic-depressive, manic. The last case had a previous attack with recovery, then a second attack at 41.
There were certain slight changes in the spinal fluid, indicating a probable organic disease. There were some symptoms of a præcox type, but the question of organic brain disease cannot be easily ruled out.
Accordingly, we can summarize the manic-depressive to dementia præcox changes by saying that in four cases the changes in diagnosis may be seriously doubted for reasons given above; one case is a chronic mania, which is probably dementia præcox; that four cases appear to be dementia præcox from the Psychopathic Hospital records and in the other two cases the change in diagnosis may be questioned, but it is possibly correct.
One case of agitated depression at the involution period was called a post-operative psychosis, despite the absence of consciousness, disorder and hallucinations and a persistence of the process for two years. In this case I should certainly believe involutional melancholia to be the proper diagnosis.
A case with three attacks of manic-depressive psychosis spent two of them at the same hospital which finally diagnosed his case alcoholic dementia, despite the rather typical manic picture shown.
Another very interesting manic case, with unusual features pointing to præcox, was called an alcoholic psychosis, despite the fact that our rather elaborate study of the case for three weeks failed to reveal more than a minimal use of alcohol. The symptoms were chiefly those of mania.
A hypomanic case was called a defective delinquent. To be sure, the boy was both defective and delinquent, but at the time of commitment he was certainly hypomanic. It may be noted that the diagnosis“ defective delinquent” needs to be handled with care. Such patients may also be, or become, insane-a fact frequently overlooked. From the same institution I have recently obtained a diagnosis of defective delinquent in a straight out-andout paranoid case that has been committed three times to state hospitals.
One case of depression was called a neurasthenic psychosis. With this diagnosis I have no quarrel to make, since, as I' have recently pointed out, the differential diagnosis between psychosis and psychoneurosis is often extremely difficult to make and, furthermore, many so called psychoneurotics are really insane in the technical sense of the word.
Group III.- Neurosyphilis : One would not expect to find any diagnostic errors in this group, except within the group itself (i. e., cases diagnosticated paresis turn out vascular lues, etc.) because of the exact laboratory methods which are available for aid in diagnosis. However, there is a group of cases in which we find a psychosis, or even no psychosis, plus the serology of neurosyphilis, the latter producing no symptoms which can be directly attributed to it. Such cases have been reported in considerable numbers (see Barrett,' Lowrey,!!!. Southard & Solomon," ") and several more such cases could now be added to the list.
Of the three errors in diagnoses which appear in our table only one, the case called alcoholic dementia, is of this type. This case was diagnosed “chronic alcoholic psychosis + neurosyphilis' at the Psychopathic, from which it will be seen that the major importance of alcohol was recognized, but the presence of neurosyphilis was also indicated. The two cases called dementia præcox by other hospitals are clearly, from our records, dementia præcox and there is no serological evidence to back up a diagnosis of neurosyphilis and I do not understand how such a diagnosis was made. A final case, which I have not classed as an error, was called “luetic paranoid " at the Psychopathic and“ general paresis +paranoid dementia præcox” at the other hospital. I should feel that our diagnosis was probably more logical. At any rate, I should want some extremely good evidence of the existence of the usual symptoms of paresis before I made a double diagnosis. However, both diagnoses recognized the relationship: neurosyphilis +paranoid psychosis.
Group IV.-Acute Alcoholic Psychosis: Of the four errors in this group of 12, one in which we raised a question of dementia præcox has been discharged as self-supporting, although somewhat dull. Another case called manic-depressive, manic, is said to show blunting, probably due to the use of alcohol. One case called by us alcoholic hallucinosis has been discharged recovered from a toxic insanity. Of course alcoholic hallucinosis is a toxic psychosis, but is a more exact diagnosis than merely toxic. Another patient called by us alcoholic hallucinosis has been discharged as a recovered case of dementia præcox. We are all aware that in a typical case of alcoholic hallucinosis, the differential diagnosis is alcoholic hallucinosis versus paranoid dementia præcox. The differentiation is to be based upon three factors: 1, The history of the abuse of alcohol in a person who was previously regarded as normal; 2, the normal emotional response to the ideas and hallucinations entertained; 3, the outcome in recovery in from four to six weeks, with good insight into the past mental illness. Accordingly, I should suspect that in two, and perhaps three of these cases the Psychopathic diagnosis was more nearly correct, judging by the history, symptoms and outcome, than the diagnosis in the other institutions.
Group V.-In the chronic alcoholic group, the two cases in which the diagnosis was changed to "not psychotic " did not present enough deterioration at the Psychopathic Hospital to be committed as insane, but were sent to the institutions as habitual drunkards." So that, although I have classed them as errors in the table, they are really not such, since in both cases the other institution makes a diagnosis of “inebriate." The third case, however, is a rather interesting one of aphasia, in which the other hospital diagnosis of arteriosclerosis seems to be correct.
Group VI.-Senile Group: One case was diagnosed as an organic dementia which really amounts to saying that there is dementia due to some type of organic disease. It does not, however, make any exact diagnosis of the organic disturbance. A second case was called manic-depressive psychosis, apparently due to some history which we had not obtained. In a third case the diagnosis was changed to cerebral arteriosclerosis. Of course the differential diagnosis between senile dementia and arteriosclerotic psychosis is not always easy and in many cases represents a question of evaluation of indirect evidence more than anything else. One interesting case, which we called a senile
psychosis, was discharged "improved ” with a diagnosis of “not insane" from the hospital to which she was sent. This woman's daughter, who was about 40 years of age, had a marked paranoid psychosis of slow development. The two women lived alone and the daughter convinced the mother of the reality of her delusions and hallucinations, and the old lady firmly believed them. We called it a senile psychosis although she was not demented.
Group VII.-Epilepsy: There were no disagreements in the diagnosis of epilepsy and we missed no diagnoses of epilepsy. This is probably to be explained by the fact that the epileptic cases which we see have usually a long history of fits or perhaps have some while they are in the institution. There has not always been verbal agreement as to the diagnosis of epileptic psychosis, but that of course may be due to a clearing up of the psychotic state at about the time of discharge to the other institution.
Group VIII.-Arteriosclerotic Psychoses: On the surface it appears that our least accuracy in diagnosis lies in the field of the arteriosclerotic psychoses. The diagnoses returned by the other institutions concurred with us in only 12 of 22 cases and in addition seven cases called by us something else are called arteriosclerosis by the institutions.
Three cases were called senile dementia. As was pointed out above, this differentiation is often very difficult to make, especially in the more advanced cases, and it often represents an interpretation of certain equivocal signs and an evaluation of conditions which can only be indirectly estimated. Accordingly, although these diagnoses are erroneous, the error is perhaps not a particularly serious one.
Two patients were called organic dementia, just as a case diagnosed by us “organic dementia” was called “ cerebral arteriosclerosis " in the other institution. Of course, as pointed out above, organic dementia is not a diagnosis in the ordinary sense of that word, it is merely a recognition of state and a partial putting together of symptoms. Another case is regarded as one of chronic alcoholic psychosis. Here again the major symptomatology is much the same in the two conditions and differentiation depends upon history and the evaluation of certain signs. In this case there is an alcoholic history, but there are also signs of cerebral arteriosclerosis. Another case was left "unclassified,"