side of the question has been comparatively neglected. For many years such psychoses as were observed were considered to be the direct result of the Graves' disease, and have often been classified as Graves' psychosis. In text-books of psychiatry usually little or nothing is to be found concerning this subject. More recently attempts have been made to answer some of the questions above, and the analyses of a few cases here and there have given rise to some doubt as to the direct relationship between Graves' disease and the psychoses associated with it. Numerous opinions have been expressed, some to the effect that both the Graves' disease and the psychoses had a common etiology based upon auto-intoxication or inherited degeneracy; and some, recognizing the similarity between many of the psychoses seen with Graves' disease and in manic-depressive insanity, have gone so far as to suggest that in all cases of manic-depressive insanity we have as an etiological factor some disease of the thyroid. It will not be attempted to discuss these various theories, but merely to present an analysis of the cases collected and to draw some conclusions from the results.

The present collection of 82 cases includes 20 men and 62 women. In dealing with them, the fact was at once striking that of the 54 cases in which the heredity was stated, 63% showed a heredity for mental disease. In six cases there was also heredity for Graves' disease. In 26 cases, 32% of the total number, there

, were evidences of a neurotic or psychopathic make-up, and this figure is probably much too low, since in many cases no sufficient data were given to allow one to judge concerning this point. In this same connection is to be noted that 12 cases, 15% of the total number, had had psychoses previous to the onset of any objective symptoms of Graves' disease. Two had had more than one previous attack; in one case a psychosis had preceded the Graves' disease by two years, in one by eighteen years, in one by seventeen years, in two by five years, in one by four years, and in the remaining six the exact time was not given.

The age at onset of the Graves' disease varied from 18 to 63 years, the average being 33.9 years. Likewise the age at onset of the psychoses showed a wide variation, 18 to 66 years, the average being 35.8 years. That is, the psychosis came, on an average, about two years after the Graves' disease.

A more careful examination of the intervals gives some interesting information. In 22 cases the interval was not given. In 32 cases the onset of the Graves' disease and the psychosis was practically simultaneous. Among the remaining cases a one-year interval was noted in three, a two-year interval in five, a three-year interval in eight, a five-year interval in four, a six-year interval in one, an eight-year interval in two, and a ten-, eleven-, twelve-, thirteen- and twenty-year interval in one case each. That is, in 32 cases, or 52% where the interval was known, the onset of the Graves' disease and the psychosis was practically simultaneous, in the remaining 48% the curve of the intervals rises rather quickly to three years, and then falls again more slowly. This at once suggests the question of whether or not we are dealing with two different kinds of cases. A further analysis shows that 85% of the simultaneous cases had a bad heredity, as against 36% of the cases where the psychosis was later in onset, or from the opposite standpoint, only 15% of the simultaneous cases had a good heredity, while a good heredity was found in 36% of the cases with a later onset of the psychosis. It is also interesting to note that 50% of the simultaneous cases had a bad make-up, while only 26% of the cases with later onset of the psychosis had a bad make-up. Again, 19% of the simultaneous cases had had previous psychoses, while only 11% of the cases with later onset of the psychosis had had previous attacks. In regard to the various symptoms noted in the psychoses of the two classes, i.e., the simultaneous cases and those with later onset of the psychoses, there is not sufficient variation for significance.

If we turn next to a consideration of the more striking symptoms shown in the psychoses of all cases, we find that there was a depression in 53 cases, 65%; excitement in 51 cases, 62%; delusions in 40 cases, 49%; apprehensiveness in 37 cases, 45%; irritability in 33 cases, 40% ; exhilaration in 23 cases, 28%; hallucinations in 23 cases, 28% ; incoherence in 13 cases, 16%; delirium in II cases, 13%; seizures in 8 cases, 10%; memory defect in 7 cases, 9%; paraphasia in 3 cases, 4%; phobia in 3 cases, 4%. (Cf. the table, p [8a].)

A study of the depressions shows that at some stage of the psychoses 23% of them showed exhilaration, and what is more striking, 58% and 59% of them showed, respectively, excitement and

a

apprehensiveness. Such a combination of symptoms, while often seen in cases at the involution period, is rather striking in such a large percentage of cases whose average age is about 35 years. 51% of the depressions were deluded, which is perhaps of no great significance. 45% of the depressions were notably irritable, perhaps a larger percentage than would be seen in depressions in general.

Of the 23 cases showing exhilaration, 52% at some time in the course of the psychoses were also depressed. This leaves a comparatively small percentage of the whole number, only about 12%, who showed only an exhilaration without a depression. 100% of the 23 exhilarations showed excitement; i. e., if we may be allowed to speak in terms of manic-depressive insanity, we found among the depressions a great tendency to mixed states characterized by depression with motor activity, whereas among the exhilarations we found no tendency to the opposite kind of a mixed state-manic stupor-exhilaration without motor activity. Furthermore, there was a high percentage of irritability, that symptom being present in 61%.

From the standpoint of excitement, of the 51 cases showing this symptom, 61% were depressed, and 45% exhilarated, again emphasizing the large number of mixed states where depression was associated with motor activity. Under this heading we again notice a high percentage of irritability, 51%, as might perhaps be expected. Apprehensiveness occurred in 43%, and delusions in 48%. These figures are mentioned because they occur among the higher percentages, rather than because of any special intrinsic significance.

Considering the 33 cases with irritability, we may briefly note that 79% of them were excited and 66% depressed, again indicating the prominence of these symptoms from another viewpoint.

From the standpoint of apprehensiveness, 86% of the 37 cases showing this symptom were, as might be expected, depressed. 59% were excited, 54% deluded, and under this heading we for the first time find hallucinations rising to a large percentage, viz. ;

41%.

Twenty-three cases, 28% of the total number, had hallucinations, mostly of hearing, some of sight, and what is perhaps particularly striking is that 70% of these cases were depressed. Otherwise nothing special stands out under this head.

a

Forty of the cases had delusions, 68% of these were depressed, 62% excited, 62% apprehensive, 50% irritable. This seems to emphasize the prominence of apprehensive delusions.

The 13 cases showing marked incoherence showed also, as may be expected, a large percentage of excitement and exhilaration, with 62% irritable.

Only 11 cases had a marked delirum, and in this connection only two high percentages are to be noted : 91% were excited, and what is more significant, 82% died, the highest per cent of deaths recorded under any heading.

The number of cases with memory defect, seven, is too small to make an analysis of any value. It is perhaps interesting to note that two were under 30 years of age, one was 32 and had had seizures, one was 43 and had become demented in about six months, one was 48 and was paraphasic; the other two were 43 and 46 years of age, respectively, showing that the memory defect could not be ascribed to senility, and in half of them at least there was slight probability of arteriosclerosis.

Paraphasia was noted in only three cases; all were decidedly irritable. No other characteristic was common to more than one case.

Phobias were also noted in three cases, and they were simply apprehensive and depressed.

Eight cases had had seizures; four were exhilarated and four depressed. 87% were excited. The ages here again indicate that on the whole they were rather young; thus two were under 20, four were under 35, one was 42, and one 66 years

of
age.

Five of these cases died within a comparatively short time, the second highest percentage of deaths noted under any heading.

When it comes to a consideration of the outcome, the great majority of cases passed from observation in an unimproved condition and the further course is unfortunately not known. Four cases improved; they had all been excited and irritable. Three of them had been both exhilarated and depressed. In one case the mood was not mentioned as either exhilarated or depressed, but improvement followed after two years of excitement. In three other cases the exact durations were not given. The ages in these cases which improved were 18, 20, 31, and 35 years.

Ten cases recovered from their psychoses; eight had shown a depression with excitement, one an exhilaration with excitement, and one an exhilaration followed by a depression with excitement. In two of these recovered cases the Graves' disease and the psychoses had come on practically simultaneously as the result of taking thyroid, and in both cases the physical symptoms had disappeared on the withdrawal of the drug. In the remaining eight cases the mental symptoms disappeared without corresponding disappearance of the physical symptoms. In three cases there was no improvement noted in the physical symptoms, in five cases a partial improvement. The ages of these recovered cases were 23, 24, 27, 30, 37, 43, 53, and in the three remaining cases the age was not given. The hereditary data in these cases indicated little. In three there was a bad heredity, in four a good heredity, and in three the data were wanting.

Only two cases were known to have demented. Both began with apprehensive depressions and one became delirious. The ages were 26 and 43. 25 cases, or 30% of the total number, died under observation, quite a large proportion considering the fact that so many passed from observation in a comparatively short time. 88% of them had been excited, and under the heading of excitement we noted that 43% of the excitements died, the third highest mortality noted under any heading, the highest being, as above noted, 82% of the delirious cases, and the second highest, 75% of the cases with seizures. 52% of the deaths had shown depressions and 32% exhilarations ; 36% had been apprehensive, and 24% had had seizures. Among those that died the average duration of the psychosis was thirteen weeks, the median duration was six weeks. Four cases died within a week, four within two weeks, three within a month, six within two months, three within three months, one within a year, and one within two years. In three cases the duration was not known. The ages varied from 18 to 62 years, the average being 35 years. Three were under 20, five under 30, five under 40, seven under 50, one under 60, three under 70. In regard to heredity among the cases described, the figures are too small to be of much account. In ten of the 25 information was wanting; in the remaining 15, ten had a bad heredity and five a good heredity.

Such, then, are some of the most important statistical data gleaned from the analysis. In order that anyone may make use