THE PSYCHOSES WITH OTHER SOMATIC DISEASES
Mental disturbances of various types associated with somatic
conditions and not sufficiently characteristic or circumscribed in
their symptomatology to constitute definite and separate psychoses
have long been recognized. That delirium is a complicating factor in
certain acute febrile diseases has been known for centuries. Aristotle
called attention to the occurrence of hallucinations and illusions
during the course of fevers. Hippocrates referred frequently, not only
to excitements, but to delirium and phrenitis. The word "delirus"
appears in several places in the works of Horace and many of the
early authors apparently used this term as synonymous with both mania
and melancholia. That was probably true of Sennert. Flemming in 1844
mentioned fever delirium, hallucinatory and delusional clouded states
and an encephalitic form in addition to the various alcoholic types.
Sydenham referred to the mental symptoms associated with malaria and
Bright in his original "Reports" described other delirious conditions
at some length. Sir Thomas Watson showed that the brain was uninvolved
at autopsy in the acute rheumatic affections with apparent cerebral
complications. Mental symptoms have, of course, been associated
for hundreds of years with meningitic processes. Diabetic coma was
also recognized long since. Griesinger is said by some to have been
the first to call attention to the psychoses caused by the acute
infections. Post febrile mental disturbances were, however, referred
to by Sydenham, Baillarger, Westphal, Greenfield, Gubler and many
others. Delasiauve very elaborately described the psychoses associated
with typhoid fever in 1849. The mental disorders accompanying gout were
discussed at considerable length by Sydenham and were referred to as
early as 1699 by Philander Misaurus.
According to Bucknill and Tuke[261], Misaurus made the following
very interesting suggestions in an article entitled "The Honour of
the Gout": "It would be worth inquiry, whether the gout is not as
effectual against madness; and we may reasonably believe that it is
so, if upon examination, it should be found that there are no gouty
people in Bedlam; and then for the recovery of these poor creatures to
their wits again, it will not need much consideration, whether they
ought not to be excused the hard blows which their barbarous keepers
deal them, and the Therapeutic method of Purging, Bleeding, Cupping,
Fluxing, Vomiting, Clystering, Juleps, Apozemes, Powders, Confections,
Epithemes, Cataplasms, with which the more barbarous Doctors torment
them, and instead of their learned Torture, indulged for a time only,
a little intemperance as to wine, or women, or so; or the scholar's
delight of feeding worthily, and sleeping heartily, whereby they might
get the Gout, and then their madness were cured." Clouston described
a very definite form of phthisical insanity. Van der Kolk made the
surprising statement that phthisis and mania often alternated in
regular cycles. Nasse classified the mental conditions associated with
fevers as either resulting directly from the febrile disturbance,
constituting a prolongation of the delirium after the temperature
subsided, or developing during convalescence.
The German psychiatrists during the first part of the nineteenth
century were divided into two quite separate groups. One of these
insisted that all mental diseases were purely psychic in origin, and
the other, that they were in all instances directly attributable to
somatic disease processes. The former school was ably represented by
Heinroth and Ideler and the latter by Jacobi, Nasse and Friedreich.
This led to a controversy which lasted for many years. Heinroth's views
were illustrated by his statement[262] that "Insanity is the loss of
moral liberty. It never depends upon a physical cause; it is not a
disease of the body but of the mind—a sin.... The man who has during
his whole life before his eyes and in his heart the image of God, has
no reason to fear that he will ever lose his reason.... Man possesses
a certain moral power which cannot be conquered by any physical power,
and which only falls under the weight of his own faults.... From wrong
doing springs all misfortune, including the disorders of the mind."
His principal work was a "Lehrbuch der Seelenkunde," published in
Leipsic in 1818. The teachings of the psychic school were summarized by
von Feuchtersleben[263] as follows:—"The mind is the immediate seat
of the disease, the bodily suffering is secondary. Mental disorders
may be clearly traced to their origin, Sin, Error, Passion. Diseases
of the brain, on the contrary, and of all the organs, occur, even in
their greatest intensity, without mental disturbance, as also the
latter without the former. The psychical mode of cure is that which is
properly efficient; the somatic remedies in reality act psychically;
for instance through pain, diversion of the thoughts, stupefaction,
terror. Pathological anatomy has not discovered any decided relation
between disorganization of the brain and mental disorders." In 1836
Friedreich[264]in opposing Heinroth's views outlined thirteen reasons
for believing that all psychic disorders were somatic in origin:—"1.
Because the mind cannot become diseased; 2. because the greater part
of the causes producing those conditions is somatic; 3. because in all
mental disorders there are somatic symptoms in addition; 4. because
they are too permanent for pure conditions of the mind; 5. because
they are subject to cosmical and telluric states; 6. because their
crises always take place in a material way; 7. because they are not
infrequently removed by strong material influences; 8. because the
somatic mode of cure alone has a direct sanatory effect, the psychical
at most an indirect effect on the body; 9. because the occurrence of
psychical indisposition on one side only, must arise from the duality
of the brain; 10. because the return of reason before death occurs in
cases not only of psychical, but likewise of somatic diseases, and may
be physically accounted for; 11. because mental disorders correspond
with the temperaments; 12. because it may be proved that there are
psychical conditions which depend on organic causes, and are therefore
very analogous to psychical disorders; 13. because chronic delirium
(mania) can be no other than febrile." Absurd as such discussions may
seem at this time, they are no worse than the theological debates
of that day. As a matter of fact, they were no more futile than the
efforts still being made to classify the various psychoses on some one
common ground, for any other than purely statistical purposes.
Kraepelin[265] divides the psychoses due to infection into febrile
delirium, infection delirium, acute confusional states (amentia) and
exhaustions. The result of the infectious process, as he says, may be
merely to precipitate a manic-depressive psychosis, or an attack of
dementia praecox, general paresis or delirium tremens. It may also
be manifested in the form of a neuritis, myelitis, encephalitis, or a
meningitis. Bonhöffer in 1910 described several forms of "symptomatic
psychoses" due to infections and divided them into three main groups:
deliria, confusions and mental enfeeblements. He also referred to
epileptiform excitements, dream states, hallucinoses, manic types and
amentias either hallucinatory, catatonic or incoherent in character.
Kraepelin speaks of several definite stages or forms of febrile
delirium. In the mildest of these there is a feeling of discomfort
with a sensation of fulness in the head and a marked sensitiveness to
external impressions. In the second stage a suggestion of clouding
becomes apparent and perception is distorted by hallucinations and
illusions. There is an increased activity of the mental processes
and consciousness soon assumes a dreamlike form. Hallucinations and
illusions are mixed with realities. The restlessness increases and
excitements or depressive moods may precede the appearance of the third
stage. In this there is a more pronounced disturbance of consciousness
with disorientation, confusion, flight of ideas, and variable emotional
reactions, sometimes with actual manic manifestations. Evidences of
stuporous tendencies may appear at times. In the fourth stage a state
of weakness develops, with picking at the bed clothes, tremulous
movements and a senseless muttering of words and syllables. This
terminates in complete coma. In smallpox, scarlet fever, erysipelas,
articular rheumatism and pneumonia there are often sudden confused
excited states, while in typhoid fever stuporous delirium is the
rule. Hendriks found the mental symptoms in typhoid greater during
convalescence and not closely related to the febrile reaction. He
describes a marked disturbance of attention with little involvement
of apprehension or comprehension, but marked loss of mental capacity
and sometimes a tendency to confabulation. Visual hallucinations
and loss of sleep are common symptoms. Often there is restlessness,
talkativeness, indifference, carelessness and disturbances of
volition. In articular rheumatism and scarlet fever, according to
Kraepelin, delirium sometimes develops with sudden rise of temperature.
Restlessness, talking in the sleep, volubility or dulness precede an
unusually violent delirium, sometimes terminating in stupor and death.
The basis of these conditions in all cases is the toxic infection
causing the fever, changes in metabolism, circulatory disturbances
and an involvement of various organs, particularly the brain. A rapid
and considerable rise of temperature usually causes delirium in
typhoid, smallpox and erysipelas while it has no such effect usually
in tuberculosis. This disturbance is a direct result of the influence
of the toxins on the cortex. Alcoholism constitutes another well-known
and common cause. In seventy per cent of the cases the duration was
less than one week and the delirium disappeared with the fall in
temperature. Some cases terminate in infection delirium or they may
precipitate genuine attacks of manic-depressive insanity, dementia
praecox or general paresis.
The so-called acute alteration of Nissl was a very common change found
in the cortical cells at autopsy. This very generally involved the
entire cortex. Kraepelin describes another characteristic alteration
observed in cases of typhoid delirium. The Nissl bodies are clumped
together in the periphery, and are deeply stained, the processes also
being unusually dark. Some cells show a shrunken nucleus with swollen,
lightly stained bodies. Around these neurones there are usually large
accumulations of elongated glia cells.
In the infection delirium, so called, the mental disturbance develops
in a case where there is no hyperpyrexia or where at least there is
no relation between the psychosis and the temperature. A restless
excitement ushers in the attack. Pressure in the head, mental
dulness, depressed or sometimes cheerful moods, uneasiness, disturbed
sleep and anxious dreams are common symptoms. Later a disturbance of
consciousness appears and a special type known as "initial delirium"
may develop. This is a common occurrence in typhoid fever.
Aschaffenburg described two forms of initial delirium. The first is a
restless condition of clouding with hallucinations and delusions. The
second form, which may develop from the first, shows active mental
excitement. Mild in its onset, a confusional delirious state soon
develops with flight of ideas, hallucinations, delusions, and marked
anxiety. An initial delirium of this type often occurs in smallpox.
This assumes a particularly severe form with a tendency to suicide
and violence, strongly resembling epileptic dream states. Seizures
and epileptiform convulsions may occur. The delirium usually develops
from the third to the fifth day of the disease and mental enfeeblement
sometimes follows. The attack usually lasts from several days to a
week. It may continue as a fever delirium. About forty or fifty per
cent die. Nissl in one case found a marked congestion of the vessels
of the cortex, with an increase in the number of leucocytes, and a
widespread destruction of the neurones. The cell bodies were swollen
and the chromatin lumps destroyed. Karyokinetic changes were noted in
the glia cells.
More or less similar delirious states occur in the course of
intermittent malarial fevers. These usually take the form of a marked
anxious excitement, often with stupor or a tendency to violence.
The attacks begin suddenly, last only a few hours and end in
sleep. Convulsions are frequently observed. These conditions occur
in the quotidian or tertian types but rarely in the quartan. The
delirium precedes a febrile disturbance or may take its place. It
is apparently due to an accumulation of plasmodia in the cerebral
vessels. In influenza, restlessness, confusion, anxious excitement
or hallucinatory deliria may be associated with a low temperature.
Polyneuritic manifestations have also been observed. The disturbance
is undoubtedly caused by the influenza bacillus or the action of its
toxins on the cortex. Abscesses are found in some instances. Deliria
with phthisis are rare unless there is a tubercular meningitis. In
the septic infections, conditions with marked clouding are often
observed, and are to be attributed to embolism, metastases, etc.
Muscular weakness, aphasia, perseveration and convulsions may be
present in these cases. Infection delirium also occurs in chorea.
This takes the form of a clouded dreamlike state with confusion of
thought at times, hallucinations, delusions, and emotional excitement
accompanied by characteristic choreiform movements. Apprehension, as a
rule, is unimpaired, but attention is disturbed and the patients are
forgetful and distractible. They do not have a clear grasp on their
surroundings. Occasional hallucinations appear. The mood is anxious,
excited, fearful or irritable, sometimes with outbursts of anger or
threats of suicide. The choreiform attacks are aggravated and speech is
affected. The reflexes are decreased and muscular weakness develops.
The pupils are dilated and sleep is interfered with to a marked degree.
This excitement lasts for a short time only, but often recurs. In nine
per cent of the cases (Kleist) death results from heart failure, septic
infection or other intercurrent diseases. Wassermann and Westphal
demonstrated streptococci in the brain in several cases of chorea.
Others have reported staphylococci in the blood. Choreic delirium is
usually associated with endocarditis or rheumatic infections, and
occurs in the acute type but not in the Huntington variety of the
disease.
Delirious excitements, according to Kraepelin, also occur in acute
cerebrospinal inflammatory processes and may be due to furunculosis
or caused by infections from the mouth or the intestinal _tract_.
There is nothing particularly characteristic in such conditions aside
from their severity. They have been collectively described under the
designation of "acute delirium." Their differentiation depends entirely
on the demonstration of the source of infection. The anatomical basis
for these disturbances is always found in the cerebral cortex. The pia
is infiltrated with lymphocytes and plasma cells and leucocytes are
found in the perivascular spaces. There is also a proliferation of the
glia. The "grave" alteration of Nissl is often demonstrable. After
the infectious process passes its maximum intensity and the delirium
disappears, "residual" delusions may remain with a clear sensorium.
These may last for several days or even weeks. They frequently follow
typhoid fever. Occasionally hallucinations of sight and hearing persist
in the same way.
"Collapse delirium" was first described by Hermann Weber in 1866. It
takes the form of a stuporous state with confusion of thought, dreamy
hallucinations, flight of ideas, an unstable emotional condition and
an active motor excitement. The onset is usually sudden, following a
period of sleeplessness and restlessness. Disorientation occurs early
and consciousness is markedly clouded. Phantastic hallucinations and
illusions are frequent. Excitement and confusion are also prominent
symptoms. Flight of ideas is common and the patient often sings or
expresses himself exclusively in verse or rhymes. Senseless and rapidly
changing delusions are noted. The mood is elated, erotic, anxious or
irritable, with outbursts of anger. Motor excitement is conspicuous
and there is no sleep. Usually food is refused and nutrition disturbed
with a great reduction of bodily weight. This condition is of short
duration, usually not more than a few days, often terminating in sleep
in favorable cases. Only a confused recollection of events remains
on recovery. Collapse delirium, according to Kraepelin, is purely
an infectious process and often occurs in pneumonia, erysipelas and
influenza, following the subsidence of the active symptoms of the
disease. It occasionally complicates articular rheumatism and scarlet
fever. The characteristic features in erysipelas are hallucinations
and delusions of a delirious type, while clouded states, confusional
excitements and flight of ideas are more common after pneumonia.
The symptoms usually develop after the temperature falls and other
evidences of weakness are present. Kraepelin, however, recognizes
infection as the only cause at this time, although he previously
described these as exhaustive conditions.
Acute confusional states or amentia were described by Meynert in 1881.
These are characterized by a clouding of consciousness with multiform
manifestations of excitement both sensory and motor. Amentia is one of
the sequelae of infectious diseases. It takes the form of a subacute
development of a dreamlike confusion with hallucinations, illusions and
motor excitement lasting usually for several months. It is very closely
related to collapse delirium and the hallucinatory insanity of Hoche,
Fürstner and others. The early symptoms are sleeplessness and unrest.
The patients become anxious, forgetful, develop a fear of death, and
cannot control their thoughts, complaining of dulness and confusion
of mind. A difficult comprehension of external impressions develops.
They may be attentive and seriously troubled at not being able properly
to grasp their surroundings. A decided uncertainty and restlessness
results. Everything seems changed or false. There is at first a feeling
of inadequacy and a profound disturbance of thought which develops
into a well defined confusional condition. A dreamlike state follows,
sometimes with a tendency to fabrications. Rhymes, phrases and words
may be repeated frequently. There is a tendency towards distractibility
and flight of ideas with vague thoughts of persecution. Hallucinations
sometimes become apparent, and illusions appear. The mood is usually
one of irritable anxiety, suspicion and mistrust, seldom with complete
dulness. Occasional outbursts of anger take place. A restless behavior
is noted as a rule. Sometimes suicidal tendencies occur and mild
stuporous states follow.
In another group of cases depression is an especially prominent
feature as occasionally happens after typhoid fever; or states of
excitement may exist with a flight of ideas and delusions of grandeur.
Before the febrile disturbance has disappeared signs of restlessness
are noted. Orientation is soon lost, apprehension is disturbed, the
patient becomes distractible and begins to show hallucinations. Ideas
of grandeur develop and fabrications are conspicuous and extravagant.
The mood is angry and irritable, sometimes cheerful or elated, but
very changeable. Restlessness, volubility, flight of ideas, senseless
rhyming, confused writing and tendencies to sing, etc., soon appear.
The sleep is very much disturbed. Very little nourishment is taken or
it is refused entirely. Bodily weight is greatly reduced. The reflexes
are usually increased, the pulse slow and the temperature subnormal.
The duration of the disease is usually not more than from two to
six months. Amentia usually follows typhoid, articular rheumatism,
smallpox and cholera, and occasionally occurs after pneumonia. Symptoms
invariably develop after the fever has subsided. After typhoid the
characteristic features are excitement with hallucinations, delusions
and variable moods; after articular rheumatism, disturbance of
apprehension, restlessness, depression or even stupor; and after
phthisis, hallucinations with preservation of consciousness and slight
confusion.
Light forms of the infectious exhaustions, according to Kraepelin, may
appear after convalescence from the more severe illnesses. The patient
does not make a good recovery, is exhausted, cannot think clearly,
tires easily and is not able to read or write letters. Mental activity
is weakened and the patient remains in bed, apathetic and indifferent.
Consciousness, orientation and perception are undisturbed, although
hallucinations may appear when the eyes are closed or noises in the
ears may be noticed. The mood is gloomy, hopeless, and sometimes
irritable, with sudden attacks of anxiety at night. The patient becomes
suspicious and has fears of death or poisoning. Hypochondriacal
feelings with self-accusation may develop. Food may be refused and
suicidal attempts occur. Some cases are reserved and quiet, even
stuporous, expressing only a few delusional ideas at times. Sleep and
appetite are affected and weight lost as a consequence. These lighter
forms usually follow influenza, articular rheumatism, whooping cough,
tuberculosis or chorea. The duration is ordinarily brief—a few weeks
or months, followed by recovery. In some instances the disease may
progress to a complete enfeeblement of the mental processes.
The exhaustive conditions in a large group of more severe cases are
ushered in by a delirium or confusional state with a depressed mood.
There is first a slight anxiety. Self-accusation and persecutory
ideas appear early. Hallucinations of hearing and vision develop.
The patients soon become clouded, inattentive, show difficulty of
thought and loss of memory, with mental dulness. All grasp upon their
surroundings is lost, they fail to recognize members of the family,
and answer questions unintelligently. They have no appreciation of
their condition and no memory for events. The mood is indifferent,
apathetic or whining. It may be irritable, quarrelsome or violent.
Usually they lie in bed and are entirely apathetic. Sometimes they
show automatic movements and have to be fed. The conversation is
often incoherent and meaningless. They are inclined to be emotional.
Sleep is usually interfered with and they are restless at night. The
appetite is lost. Occasionally evidences of brain lesions appear with
paralyses, speech disturbance or epileptiform seizures. The duration
is usually a matter of a number of months. At autopsy grave cell
alterations and glia reactions are common. Rod cells are also found.
Endothelial proliferation is frequently observed in the vessel walls.
Some cases terminate in a chronic condition which may improve somewhat
in time. There may be a persistent emotional and mental enfeeblement
with indifference, loss of memory, lack of judgment and impairment
of will. These "acute dementias" represent the terminal stages of
cortical infectious processes. They have been observed after typhoid,
rheumatism, erysipelas, cholera, smallpox and malaria. Usually after
tubercular peritonitis or articular rheumatism there is a simple
mental enfeeblement, while erysipelas is usually accompanied by mild
excitements and an elated mood. The typhoid cases usually showed
irritability, with outbursts of anger and confusional states with
hallucinations and delusions. They occasionally terminate in more
chronic conditions with permanent deterioration.
After typhoid, influenza and septic infections, Korsakow's
"cerebropathica psychica toxaemica" sometimes occurs. This is the
polyneuritic psychosis similar to that caused by alcohol. There is,
however, a delirium or stupor at the same time.
The post-rheumatic psychoses have been studied exhaustively by
Knauer.[266] Stuporous attacks were found in ninety-three per cent of his
cases, following acute infections. He describes four groups showing
psychotic manifestations:—
1. Anxious delirious excitements followed by stupor.
2. Excitements alternating with stupor.
3. Stuporous depression throughout.
4. Amentia-like excitements throughout.
The essential feature of Knauer's study was an analysis of
post-rheumatic stupors. He describes these as clouded or dream
states "not different from physiological sleep and the ordinary
artificial narcoses." In them he sees a disturbance of apprehension,
an interference with intellectual processes, a retention defect, and a
loss of the power of attention. Catalepsy was found to be present in
the majority of his cases. The loss of affect was described as being
more complete than in manic-depressive psychoses. He speaks of the mood
as sad, depressed, anxious, but above all, changeable.
Generally speaking this group of psychoses due to somatic disease
is one which requires further study. We have comparatively little
statistical information on the subject as yet. The differentiation of
these conditions as outlined in the Association's statistical manual is
as follows:—
"Under this heading are brought together those mental disorders which
appear to depend directly upon some physical disturbance or somatic
disease not already provided for in the foregoing groups.
"In the types designated below under (a) to (e) inclusive, we have
essentially deliria or states of confusion arising during the course
of an infectious disease or in association with a condition of
exhaustion or a toxaemia. The mental disturbance is apparently the
result of interference with brain nutrition or the unfavorable action
of certain deleterious substances, poisons or toxins, on the central
nervous system. The clinical pictures met with are extremely varied.
The delirium may be marked by severe motor excitement and incoherence
of utterance, or by multiform hallucinations with deep confusion or
a dazed, bewildered condition; epileptiform attacks, catatonic-like
symptoms, stupor, etc., may occur. In classifying these psychoses
a difficult problem arises in many cases if attempts are made to
distinguish between infection and exhaustion as etiological factors.
For statistical reports the following differentiations should be made:
"Under (a) 'Delirium with infectious diseases' place the _initial
deliria_ which develop during the prodromal or incubation period or
before the febrile stage as in some cases of typhoid, small-pox,
malaria, etc.; the _febrile deliria_ which seem to bear a definite
relation to the rise in temperature; the _post-febrile deliria_ of the
period of defervescence including the so-called 'collapse delirium.'
"Under (b) 'Post-infectious psychoses' are to be grouped deliria,
the mild forms of mental confusion, or the depressive, irritable,
suspicious reactions which occur during the period of convalescence
from infectious diseases. Physical asthenia and prostration are
undoubtedly important factors in these conditions and differentiation
from 'exhaustion deliria' must depend chiefly on the history and
obvious close relationship to the preceding infectious disease. (Some
cases which fail to recover show a peculiar mental enfeeblement.) In
this group should be classed the 'cerebropathica psychica toxaemica'
or the non-alcoholic polyneuritic psychoses following an infectious
disease as typhoid, influenza, septicaemia, etc.
"Under (c) 'Exhaustion deliria' are to be classed psychoses in which
physical exhaustion, not associated with or the result of an infectious
disease, is the chief precipitating cause of the mental disorder,
_e.g._, hemorrhage, severe physical over-exertion, deprivation of food,
prolonged insomnia, debility from wasting disease, etc.
"Of the psychoses which occur with diseases of the ductless glands, the
best known are the thyroigenous mental disorders. Disturbance of the
pituitary or of the adrenal function is often associated with mental
symptoms.
"According to the etiology and symptoms the following types should
therefore be specified under 'Psychoses with Other Somatic Diseases':
"(a) Delirium with infectious disease (specify)
"(b) Post-infectious psychosis (specify)
"(c) Exhaustion delirium
"(d) Delirium of unknown origin
"(e) Cardio-renal disease
"(f) Diseases of the ductless glands (specify)
"(g) Other diseases or conditions (to be specified)."
A study of 480 cases of psychoses with other somatic diseases reported
from the New York state hospitals during 1918 and 1919 shows the
following types represented:—
_Number_ _Percentage_
Delirium with infectious diseases 68 14.16
Post-infectious psychoses 102 21.25
Exhaustion delirium 94 19.58
Delirium of unknown origin 36 7.50
Cardio-renal diseases 69 14.37
Diseases of the ductless glands 20 4.16
Other conditions 91 18.90
An analysis of 140 cases from the Massachusetts state hospitals in 1919
shows the following:—
_Number_ _Percentage_
Delirium with infectious diseases 48 34.28
Post-infectious psychoses 25 17.85
Exhaustion delirium 26 18.57
Delirium of unknown origin 6 4.28
Cardio-renal diseases 16 11.42
Diseases of the ductless glands 1 .71
Other conditions 18 12.85
Three hundred and sixteen cases from hospitals in nineteen other states
were reported as follows:—
_Number_ _Percentage_
Delirium with infectious diseases 69 21.83
Post-infectious psychoses 30 9.49
Exhaustion delirium 75 23.73
Delirium of unknown origin 33 10.44
Cardio-renal diseases 45 14.24
Diseases of the ductless glands 15 4.74
Other conditions 49 15.50
We have, thus, a total of 936 cases distributed as follows:—Delirium
with infectious diseases, 19.76 per cent; post-infectious psychoses,
16.77; exhaustion delirium, 20.83; delirium of unknown origin, 8.01;
cardio-renal diseases, 13.88; diseases of the ductless glands, 3.84;
and other conditions, 16.88 per cent. Four and one hundredth per cent
of the first admissions in Massachusetts, 3.45 per cent of the New
York admissions, and 2.07 per cent of admissions to twenty-one other
institutions during the same period of time were cases of psychoses due
to other somatic diseases. They constituted 2.81 per cent of 34,935
admissions to all of the institutions above noted.