the spring, one in the summer, one in the fall and two in the winter. There had been apparently no previous attacks.

The lesions were symmetrical, there being an erythema of the backs of the hands extending in some cases above the wrists and later developing into a dermatitis with ulcerations. There were also gastric disturbances, seborrhoea about the nose, inflammation of the mucous membrane of the mouth and tongue with marked salivation and diarrhoea. In the two cases which had received mercurial injections, the salivation was at first attributed to the treatment, but with the onset of the symmetrical skin lesions of characteristic appearance, the whole picture seemed more that of pellagra.

The well-nourished condition of the last patient, there being a considerable amount of adipose tissue even at the time of death, is atypical but not unknown, especially in rapidly fatal cases, and there were complicating features such as a chronic myocarditis. In every instance, the psychosis had been in existence for some years prior to the onset of the pellagra symptoms. The appearance of the latter seemed to mark the culmination of a gradual deterioration especially from a physical standpoint and might almost be spoken of as a terminal condition. In the præcox cases, as already stated, the psychosis may be considered an important etiological factor, the tendency to a faulty dietetic habit predisposing to malnutrition.

A CLINICAL SUMMARY OF 106 CASES OF MENTAL DISORDER OF UNKNOWN ETIOLOGY ARISING

IN THE FIFTH AND SIXTH DECADES.*

By E. T. GIBSON, M. D., MIDDLEtown, Conn.

A review of a large number of cases which have been studied extensively rather than intensively is not likely to be of much value unless there is something novel in the kind of material or in the point of view.

In the present paper the data of the separate cases are banal. The cases themselves include those psychoses of the involutional years which have evaded definition under all the schemata of the descriptive psychiatrists. One claim for novelty is that the cases are drawn from a psychopathic clinic, and, as will be pointed out later, more nearly approximate a complete collection of mental disorders as they actually occur than would a group of necessarily commitable cases. The other claim for more or less novelty lies in

*Read at the seventy-fourth annual meeting of The American MedicoPsychological Association, Chicago, June 4-7, 1918.

the point of view; namely, the age at onset, using the decade as unit.

The advantages of such an approach have been pointed out before, notably by Southard and Bond (AMERICAN JOURNAL of INSANITY, 1914, LXX, 779, 828). In a group which includes the involutional psychoses, the standpoint of age is obviously the logical one. To attack such a group with preconceptions of disease-processes or symptom-pictures is really to beg the question.

One is struck by the number of symptoms, syndromes and even so-called diseases which have been described as characteristic of this time of life. It would probably be admitted that agitated, depressions, certain metaphysical delusions, "Cotard's syndrome," "late katatonias," etc., do occur with greatest frequency in the 5th and 6th decades, but I have been unable to find any review of the mental disorders of this period which would permit one to form any idea of the frequency and proportional value of these features.

If it is granted that something may be gained by a review of psychoses of the involutional period, the need at once arises of having as a basis for comparison observations in other decades. As a preliminary to the present survey, a study of 6000 consecutive admissions to the Boston Psychopathic Hospital has been made. (In course of publication in the Bulletin of the Massachusetts Commission on Mental Disease.)

The following paragraphs are quoted from the summary of that paper:

The cases upon which the study is based include, in addition to groups found in state hospitals of the usual type, a considerable proportion which represents mental disorder but not "insanity" in the legal sense. These are the groups which are responsive to the special appeal of a psychopathic hospital. The statistics, therefore, as a whole, present a more accurate picture of the entire incidence of mental disorder in the community than reports from state hospitals.

The use of the decennial unit avoids to a large extent errors in statement of ages, and allows any psychotic forms characteristic of the principal epochs of life to appear more clearly. According to Table IV, the predominant diagnoses in the various ten-year periods are as follows:

Ist decade: Congenital syphilis.

2d and 3d decade: Dementia præcox with manic depressive types increasing in prominence.

4th decade: Dementia præcox still most prominent, with paresis and alcoholic psychoses increasing in males, and manic depressive psychoses in females.

5th and 6th decade: For men, the decade is characterized by the occurrence of several forms in about equal number, namely: Paresis, manic depressive psychoses, dementia præcox, delirium tremens, alcoholic hallucinosis, arteriosclerotic psychosis, etc. For women, there is a tendency to ill-defined forms which are not easily diagnosed. Of these the groups of presenile, involutional, and unclassified psychoses make up in the two decades respectively 22.1 per cent and 33.8 per cent.

7th decade and following: Senile and arteriosclerotic psychoses are the prevalent ones, comprising about half in the 7th decade and a much larger proportion subsequently.

The large proportion of cases in the 5th and 6th decades which are left "unclassified" or placed in the indefinite and unsatisfactory groups of presenile and involutional psychoses indicates the need for further work upon psychoses occurring between the fortieth and sixtieth years. In the manic-depressive psychoses the maximum for males falls for depressions in the 6th decade, for manias in the 3d. For females the maximum for both types fall in the 4th decade. Disregarding sex, manias predominate before and depressions after the fortieth year.

Dementia præcox appears equally in males and females. During the twenties males were in considerable excess, while during the thirties females were in excess; fifty-seven and seven-tenths per cent of all the females and 39.3 per cent of all the males were past 30 when admitted. The specific diagnosis "not insane" was made in 9.37 per cent of all admissions. The groups which may be considered made up of cases not committable as "insane" (though certain individuals in them may be committable) comprise together 1406 cases, or 23.43 per cent of all admissions. This group probably represents roughly an actual gain in psychiatric service to the community.

TABLE I.-SHOWING DIAGNOSTIC GROUPINGS OF 1567 CASES BETWEEN THE AGES OF 40 AND 59.

The above table (I) shows the diagnostic grouping (with many condensations) of that part of the 6000 cases which fell in the years from 40 to 59, inclusive. The last three ill-defined groups in the table make up 20 per cent of the cases in two decades, but only 10 per cent of the entire 6000 cases. In other words, we have a numerical expression of the uncertainty in diagnosis which the psychiatrist meets in cases in the involutional years.

Nature of Material.

The material available at the Psychopathic Hospital possesses some particular advantages for a study of this kind. Patients are committed by physicians, or are sent by the police, or are admitted at their own request. They are drawn from metropolitan Boston and represent fairly the incidence of mental disease (apart from delirium tremens and drug addicts) in a large cosmopolitan population. The admission rate of 2000 a year is very nearly the full capacity of the hospital, and as no admissible cases are turned away, this number is approximately the normal under the conditions mentioned, and is closely related to the actual occurrence of psychoses in the population. In the great majority of cases, the patients are under observation for a short period of the time when their mental disorders have reached a stage which renders their life in society impossible. Observation in the hospital is usually limited to this acute period, so that a full record of the mental disorders is not always obtainable. The residence of the patient in Boston, and the efficient Social Service Department allows rather better accounts of their past history than can be obtained by most hospitals for the insane. Subsequent histories of cases are usually readily obtainable in the proportion which are transferred to other state hospitals.

The data utilized included age, sex, social status, time in hospital, diagnosis (which in all cases was the collective opinion of the staff), duration of illness, Wassermann reaction, alcoholic history, a short description of the mental condition, condition on discharge, and destination on discharge. It has been possible to obtain also, in a large number a report as to mental condition from one to five years later, in those cases transferred to other state hospitals, or kept track of through the Social Service Department.