The multiplicity of diagnoses in the hospital reports arises partly because some of the hospitals and physicians still adhered, during part of the five-year period, to the older nomenclature of acute and chronic melancholia and mania, etc., while the rest have adopted the Kraepelinian nomenclature to a greater or less extent; and partly to a tendency to use symptomatic names (as confusional insanity), or specific etiological names (as myxedematous insanity), for cases which do not fall clearly within the larger Kraepelinian groups, yet which seem too definite in their nature or symptomatology to be put into the category of undiagnosticated. Not only for convenience, then, but because they seem to me to belong together, these 47 diagnoses have been distributed among nine groups.

ORGANIC BRAIN DISEASE GROUP.

The largest group is that of organic brain disease, in which there is known loss or destruction of nerve cells, whether through the late effects of a previous syphilis, or senile atrophy, or arteriosclerotic malnutrition, or pressure by tumors, or as the result of hæmorrhage or other trauma, embolism, or thrombosis. The reported diagnoses classed in this group are senile insanity, general paralysis, coarse brain lesion, organic brain disease, choreic insanity, the latter being undoubtedly the dementia of Huntington's chorea. The diagnoses in this group are probably pretty accurate, and the percentage of probable error is very small. Of this group 3609 cases were admitted, 24.4 per cent, or nearly a quarter, of all admissions; 3352 cases were discharged, 28.1 per cent of all discharges. There was but one alleged recovery, which was doubtless an error either in diagnosis or in estimation of the condition on discharge; 88, or 2.3 per cent of those belonging to this group who were discharged, were returned to the community able to work enough to support themselves; 2762, or 82.4 per cent of this group who were discharged, died, a very high mortality, as would naturally be expected. Prevention may be effectively applied to one-third of this group-general paralysis. Cures cannot be expected.

DEMENTIA PRÆCOX GROUP.

The next largest group, nearly as large as that of organic brain disease, is the dementia præcox group, comprising 3585,

or 24.2 per cent of admissions, and 2813 or 23.6 per cent of discharges. The fundamental pathological condition underlying the symptoms of this large group is unknown, though recent investigations by Sioli' point to the possibility of definite cell changes being demonstrated. At all events the permanent mental defect suggests the probability of permanent brain-cell changes. It is possible that in a few cases the destructive process, if such there be, may be arrested before the damage it has done is irreparable, repair may take place, and recovery occur; but this is not often, and, in the absence of known pathology, there is always doubt of the correctness of the diagnosis in the cases that recover. I have classed as belonging to this group the diagnoses dementia præcox, paranoid condition, delusional insanity, chronic dementia, secondary dementia, chronic mania, obsessional insanity. The probable error of diagnosis in this group is considerably larger than in the previous one. More cases doubtless belong in this category than are here assigned to it, a large proportion of the undiagnosticated cases, some at least of the paranoia group, and probably some from the manic-depressive group, undoubtedly belonging here. On the other hand, some of the cases classed here probably belong in the manic-depressive group. The difficulties of diagnosis are largely among these two groups, and those of paranoia and involution psychosis. Of this group, 106, or 3.7 per cent, recovered; 356, or 12.6 per cent, became capable of selfsupport; while 1146, or 40.6 per cent, died. The rate of recovery or capability of self-support is quite low, the mortality pretty high. We do not yet know against what to direct preventive efforts, nor curative measures, as far as this group is concerned. Re-education of the demented, however, holds promise of some amelioration.

MANIC-DEPRESSIVE GROUP.

The next group is the manic-depressive group, the fundamental change in which is fatigue, or a closely analogous condition, as it seems to me; that is, a diminution of functional capacity due to functional over-activity. It would take too much time to give the reasons for this belief, so I will not attempt it. The diagnoses

1 Sioli: Histologische Befunde bei Dementia præcox. Author's abstract in Zentralbl. f. Nervenheilk. u. Psych., Mar., 1909, p. 220.

included under this head are numerous, including manic-depressive insanity, confusional insanity, neurasthenia, acute melancholia, hysterical insanity, acute mania, traumatic insanity, periodic or recurrent insanity, psychosis with somatic disease, insanity of pregnancy, exhaustion psychosis, amentia, compulsive insanity, acute hallucinosis, Graves' disease. I shall not attempt to defend this grouping, for, as in the case of the preceding group, the probability of error in diagnosis is fairly large, some cases classed here undoubtedly belonging to that group and vice versa. I will say, however, that I made this grouping of the diagnoses before determining the figures belonging to them, with the exception of traumatic insanity, which I first placed in the organic brain-disease group; but it was evident that the outcome of these cases precluded any permanent organic brain disease, and they were probably, therefore, rather of the accident neurosis type.

Of the manic-depressive group 2591 cases, or 17.9 per cent of all admissions, were admitted, and 2268 cases, or 19 per cent of all discharges, were discharged. Of the latter, 1054, or 46.4 per cent, recovered; 308, or 13.5 per cent, became capable of selfsupport, and 385, or 17 per cent, died. The recovery rate here is large, the mortality comparatively low. Believing, as I do, that fatigue is at the bottom of these cases, prophylaxis should be directed to education of the public in the perils of overwork, and treatment to the resting of these cases. Efforts in both directions should prove useful.

TOXIC GROUP.

The toxic group consists of those cases. in which there is a known poison introduced into the system from without, as in alcoholism and other drug psychoses, or in which a toxæmia can be inferred on pretty strong grounds, as in the deliria of acute infectious diseases and the psychoses in which there is clearly demonstrable metabolic change. The grounds for asserting that dementia præcox, for example, is due to a toxæmia are, as yet, quite inadequate. The diagnoses included in the category of the toxic group are acute and chronic alcoholic insanity, acute and chronic toxic insanity, acute delirium, delirium with somatic disease, Korsakow's psychosis, myxedematous insanity. Of this group, 2150 cases, or 14.5 per cent of all admissions, were ad

mitted, and 1668 cases, or 14 per cent of all discharges, were discharged. Of the latter, 829, or 49.7 per cent, recovered, and 311, or 18.6 per cent, became capable of self-support; while 277, or 16.6 per cent, died. The mortality is comparatively low, while the proportion of cases recovered or capable of self-support is large, as would be expected. Here, again, prophylaxis through education of the public, and curative measures, should be especially fruitful.

DEFECTIVE GROUP.

The fifth group comprises the cases of imperfect development, and includes the diagnoses of imbecility, mental deficiency, psychopathic inferiority, constitutional inferiority, fixed ideas, and moral insanity. Of this group there were 886 admissions, 5.9 per cent of the total, and 489, or 4.1 per cent, discharged. Of the discharges, 3, or 0.6 per cent, were classed as recovered; this was doubtless an error of diagnosis or of estimation of condition on discharge, and probably arose from a defective having an intercurrent psychosis or an acute exacerbation of symptoms which completely subsided ; 79 patients, or 16.1 per cent of the discharges belonging to this group, were capable of self-support; and 172, or 35.1 per cent, died. The proportion capable of independent existence is small, the mortality pretty high. The size of this group does not indicate the proportion of defectives in Massachusetts, but only of the defectives who become insane or are committed as such to the hospitals for the insane. In future generations something may be accomplished in the way of prophylaxis, and by wise treatment, much in the way of amelioration, of defect psychoses.

EPILEPTIC GROUP.

Epileptic insanity, the psychosis which sometimes develops in epilepsy, and which is of unknown pathology, comprises the sixth group. This does not include epileptics as such, but only the insane. There were 647 cases admitted, 4.6 per cent of all admissions; and 456 cases discharged, or 3.8 per cent of all discharges. Of the latter, I, or 0.2 per cent of the discharges of this group, recovered; 31, or 6.8 per cent, became capable of self-support; and 277, or 60.7 per cent, died. The mortality is

very high, the proportion of these returned to the community as self-supporting individuals is small. Here, again, prophylaxis is difficult, and treatment is largely ameliorative.

INVOLUTION GROUP.

The next group, a comparatively small one, includes the cases of depression coming first at the involution period of life, usually chronic, and leading to dementia, though not necessarily so. Dreyfus has tried to show that they are really cases of manicdepressive depression, but his demonstration, though able, is not clearly convincing. Its pathology is unknown. The diagnoses included in this group are involution psychosis, melancholia, and chronic melancholia. Some of the cases here figured doubtless belong in the manic-depressive group, a few in the dementia præcox group, and possibly some in the organic brain-disease group. But since there are probably a few cases in each of those groups that would, if carefully diagnosticated, fall in this one, I assume that errors approximately balance each other, not only here but among the other groups as well. Of this group there were 539 cases, 3.6 per cent, admitted, and 414, 3.4 per cent, discharged. Of the discharges, 41, or 9.9 per cent, recovered; 53, or 12.8 per cent, became capable of self-support, and 174, or 42 per cent, died. The proportion of those able to support themselves, is rather small, the mortality is high. As in the case of the dementia præcox group, we are at a loss to know at what to direct our efforts at prevention and treatment.

PARANOIA GROUP.

This small group consists of those cases of delusional insanity which begin fairly early in life, and is characterized by the gradual evolution of a system of delusions which grows more and more extensive, until almost everything and everybody in the universe is involved in it; it is chronic in its course, and, progressively, more and more trivial things and events come to have significance as confirming the patient in his delusions. There is no loss of initiative, or of interest in the daily affairs of life, or of memory. The

Georges L. Dreyfus. Die Melancholie: ein Zustandsbild des Manischdepressives Irreseins. Monograph. Jena, 1907.