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[ aQrticle

Dr. ERNA HOCH, M.D., D.P.M.,

Nur Manzil, Psychiatric Centre,
Lai Bagh, Lucknow.
To a foreign psychiatrist working
amongst patients of a different culture, the
differences and similarities in the sympto-
matology of mental illness naturally pre-
sent a fascinating field for studies. By
trying to evaluate, how cultural influences
are changing a pattern of illness in a parti-
cular diagnostic group, one might, more
easily than if one only sees patients of one's
own country, learn to distinguish, what is
accidental and what is essential in a parti-
cular type of mental or emotional distur-
After my coming to India in April 1956,
it did not take me long to notice that,
while in Indian patients schizophrenic
manifestations often differ considerably
from those we are used to in Europe, one
can hardly ever go wrong in recognizing
cases of manic-depressive illness. I found
here the same familiar complaints, the
same predominance of pyknic body-types,
the same reaction to an attitude of sym-
pathetic understanding and patient reas-
surance as I had been used to meet in my
patients in Switzerland. This confirmed
my conviction, which I still keep up in
spite of others who refuse to make a dis-
tinction between various forms of depres-
sion, that manic-depressive illness is a de-
finite morbid entity, presumably with some
biological foundation. As such it is to be
distinguished from reactive depression,
neurotic depression, depressive syndromes
occurring in the course of other psychoses,
involutional depression and a particular
Contents of Depressive
Ideas in Indian Patients
type of depression which is best characte-
rized as exhaustive depression. (See also
Kielholz (1) ). This classification does
not exclude the possibility that occasional-
ly we may be in doubt, into which cate-
gory to place a particular case. In young
patients, e.g., it is often very difficult to dis-
tinguish in the first phase of illness,
whether a manic or depressive episode is
more of cyclic or of schizophrenic charac-
ter, while in the elderly patient one may
hesitate, whether to diagnose a genuine
endogenous mania or depression or to call
it an involutional depression or senile
mania. Family-history, body-type, pre-
morbid personality and ultimate course of
the illness often help to make the distinc-
tion, where symptomatology alone does
not point clearly enough towards a defi-
nite diagnostic group. Furthermore, one
may of course have to differentiate etiolo-
gical or precipitating factors, which in an
individual case may suggest more a con-
stitutional bias, in some other case a more
psychogenic origin. Phenomenologically,
however, I find that the patients with
manic-depressive illness form a quite cha-
racteristic group, which is absolutely com-
parable to patients of the same category in
Europe. (See also Hoch (2) ).
Having been tempted for quite some
time to investigate this similarity of manic-
depressive patients in Europe and India
more closely, I was finally stimulated into
undertaking the present study of the con-
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January 1961 ] Contents of Depressive Ideas in Indian PatientsHoch
tents of depressive ideas by a letter from
an Austrian colleague, which reached me
last summer. Dr. H. Lenz, retired lec-
turer in psychiatry, of Lenz, wrote to me,
as follows : ( 3) .
"For some time past I have been busy
investigating the changes to be noted in
the psychopathology of the major psycho-
ses during the last 50 years. I have just
terminated a study on 376 depressions, in
which I found mainly that the tendencies
towards guilt and suicide are decreasing."
Dr. Lenz then makes some remarks on
the change in contents of ideas in schizo-
phrenic patients and goes on to discuss his
findings :
"As far as I can see, this change in psy-
chopathology is due to a great extent to a
change in the spirit of the age. This in-
sight again is important for a biologically
oriented psychiatry, which ought to con-
sider symptoms that are, as far as possible,
independent of variations due to the at-
mosphere of an age or to psychological
"In connection with these problems, I
should be very much interested to know,
which, nowadays are the main symptoms
in melancholia or endogenous depression
and paranoid schizophrenia in India, a
country or cultural unit which is so diffe-
rent from the Western cultural sphere. I
can imagine that in India, corresponding
to the different attitude of man towards
material possessions, religion etc., a quite
different spirit might still reign the epoch,
and that this might have its consequences
also for the psychopathological manifesta-
tions of depressions."
To this I answered in November 1959,
promising to compile some figures about
the contents of depressive and paranoid
ideas. ''Meanwhile, however," I wrote, "I
can already tell you now that any material
gained in this way may not necessarily
give a valid answer to your questions. We
shall only know, what the contents of the
ideas of those patients who are already
"civilized" enough to come to a psychiatric
clinic. . . . Our patients, who come mainly
from Lucknow, but also from the whole
Province of Uttar Pradesh and beyond,
from all over India, are a selection of peo-
ple who already have somewhat more en-
lightened ideas about mental illness. Apart
from this, it is often a mere matter of
chance that they have heard about our cli-
nic. So one could easily imagine that the
very patients, whose ideas still have got a
strongly magic, animistic content, first of
all would not know about a clinic of this
kind, and, even if they knew, would be far
more likely to take treatment from some
magician, fakir or quack. Apart from
this, if one really wanted to be exact, one
would have to divide up the observed pa-
tients according to religion and caste. It
seems a fair assumption to me, that a mem-
ber of the caste of merchants may rather
have ideas of improvement, while a Brah-
min may more easily produce idas of sin-
fulness and religious doubt."
"Theoretically speaking, or perhaps even
when taking certain practical experiences
into account, it seems quite plausible to me
that the contents of ideas should change
with the spirit of the time. If one assumes
that, fundamentally, illness usually is in
some form an excuse for one's refusing to
accept life as it is or to accept oneself as
one might be, the "excuse" naturally has
to be valid, not only for the patient him-
self, but also for his surroundings. A phe-
nomen of this kino".has been observed in
the change of symptoms in war-neuroses.
As soon as some "hiding-place" has been
exposed as such by science or public opi-
nion, new, and more valid excuses and
escapes have to be found."
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Indian Journal of Psychiatry
[ Vol. Ill No. 1
A short while ago he sent me a reprint
of a paper of his, entitled : "Introduction
to the problems of Diagnosis and Treat-
ment of Depressions", published in the
"Wiener klinische Wochenschrift'' ( 4) .
In this paper, Lenz enters into the ques-
tion of the leading symptoms of endogen-
ous depressions and their variations in the
course of time and in different areas. He
states that by older authors guilt-feelings
were named as the essential symptoms of
endogenous depression. More recently,
e.g. in a paper by Von Orelli, (5) pub-
lished in 1954 in Switzerland, it has been
shown that during the past 75 years guilt-
feelings have become less predominant.
In his own material, Lenz (4) only found
them present in 50% of the cases, while in
previous investigations this figure was
about 75%. He comments on this :
"One would have to conclude from this
that guilt-feelings have no immediate con-
nection with the essence of depression, but
only indirectly. Guilt-feelings possibly
are far more due to the concept which the
patient has made for himself or taken over
from others about God and the world. In
some, as yet unpublished, papers I have
tried to show up, how the increasing ap-
preciation of our "ego" takes a more or
less parallel course with a diminution of
interest in and attachment to Christian re-
ligion. This would also explain the de-
crease of guilt-feelings."
Lenz then makes a statement, for
which he mentions Prof. Urban of Inns-
bruck (who has been in India several times
and has studied Buddhism at Nalanda
University), Prof. M. Boss and myself
as witnesses and sources. I cannot
quite imagine, how, from my statements
which I translated to you, he could have
got the following ideas, which certainly
misrepresent matters. He writes :
"In endogenous depressions of Hindus,
and endogenous depression occurs in
India just as much as here, no guilt-feel-
ings are known, a fact which can easily
be explained from the philosophical and
religious point of view of Hinduism.
When, however, a Hindu who is convert-
ed to the Christian faith, falls into endo-
genous depression, he too will suffer from
guilt-feelings According to Lehmann
(6) non-Christian, primitive Africans also
manifest no guilt-feelings or self-accusa-
tions during endogenous depression. Ano-
ther author, Volkel (7), recently seriously
questioned the value of guilt-feelings for
establishing the diagnosis of an endogenous
Lenz then turns to the question of sui-
cide, which by some authors also has been
considered as a central phenomen in the
psychopathology of depression. One
notes, however, that in certain European
regions (the author names Holland and
Sachsen, a province of Germany), the fre-
quency of endogenous depressions is equal,
but the frequency of suicide committed
during endogenous depression is quite dif-
ferent, in accordance with the rate of sui-
cide in the total population of the two
countries. It seems that the rate of sui-
cide varies in different epochs. From the
material of the Central Statistical Office of
Austria one has to conclude that during
the last 20 years the figure for suicides has
significantly decreased. Quite independ-
ently of this figure, about which he only-
heard later, the author also stated a de-
crease of suicidal tendencies during the
last 20 years in the 367 depressive patients
investigated by him. Lenz assumes that
similar variations, due to cultural sur-
roundings and the "spirit of the age",
might also be proved with regard to other
ideas, such as the illusion of impoverish-
ment and hypochondriac symptoms.
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January 1961] Contents of Depressive Ideas in Indian PatientsHoch 31
Noticing all t hese variations in symptoms
t hat wer e once supposed to be central and
essential, Lenz asks, what , after all this,
should be consi dered as "t he fundament al
syndrome of endogenous depression, one
t hat is present in every depression without
regard to person and life-situation, t he im-
medi at e and t angi bl e expression of that
vital sadness, whi ch K. Schneider ( 8) con-
siders as t he ul t i mat e, i rreduci bl e basis of
all depressions, and whi ch Wyr sch ( 9)
names "motive-less, vital mel anchol i a".
Lenz calls t he basic syndrome, which he
found in 90% of his cases all t hrough the
50 years of observation, t hat of "complain-
ing of bei ng wi t hout " or "bei ng deprived
of". He explains it as "a complex syn-
drome, t he expression of a loss of all func-
tions and relationships of man in this world
and beyond it. Loss is t he essential con-
t ent of all depression. Newer authors
(von Gebsat t el (10) and E. Strauss (11) ),
illuminating t he phenomenon of depression
from anot her side, have charact eri zed it as
a st oppi ng of t i me and t he possibilities for
devel opment given by t i me. " Lenz then
describes, how this syndrome of "being
wi t hout " can start with t he vegetative func-
tions, i.e. loss of appet i t e, loss of sleep;
t hen comes loss of joy, loss of interest, loss
of power of decision, loss of j udgment , loss
of activity, loss of pl anni ng, loss of aim,
loss of values, loss of meani ng, loss of con-
solation, loss of courage, loss of hope, loss
of peace and loss of faith. Though such
sympt oms also occur in other types of de-
pression, t he characteristic feature of endo-
genous depression is seen by Lenz in t he
intensity and universal extent of t hese com-
plaints of "bei ng wi t hout ", also by t he fact
thar out war d circumstances pl ay hardly
any role in produci ng them. He points
out that, in mania, this syndrome of "being
wi t hout " is changed into its opposite : t he
mani c pat i ent has everything, commands
everything, is in contact with everyt hi ng,
not only at present, but even in future.
Lenz t hen adds, and in this he is qui t e
correct, t hat this syndrome of "bei ng wi t h-
out' ' is also found in t he depressions of
Hi ndu pat i ent s.
It woul d of course be begging t he ques-
tion to ask, whet her in my case-material,
which, wi t h only 53 cases of endogenous
depression is perhaps rat her too small, this
vital syndrome of "bei ng wi t hout " also is
present. In more or less the form describ-
ed by Lenz, I actually made it t he crite-
rion for classifying a depression as endo-
genous, taking into consideration, of
course, such factors as family-history,
body-type, previous mani c or depressive
phases, ul t i mat e course of the illness and
response to treatment. So, what I woul d
call the "vital syndrome' ' , was present in
all t he cases. As I mentioned in t he be-
ginning, it is amazing to find, how similar
the complaints of Indi an patients are to
those one is used to find in the West : t he
same decline of all vital functions, t he same
lack of faith, hope, confidence, t he same
experience of a closed world, of a dark cur-
tain that has fallen down over everyt hi ng
or of time having come to a stop. It
might be interesting t o investigate t he ver-
bal forms of expression used to desi gnat e
this experience. Our records do not allow
in all cases to examine this. But 1 should
like to point to the difference in a general
way of formulating depressive experience :
The term "depressi on" indicates t hat t he
subject feels weighed, pressed down. In
German we talk about . "Schwer mut ",
which perhaps could best be translated as
"heavy mood". In Hi ndust ani we hear t he
patient say : "Tabi at girti". Whi l e "de-
pression" indicates a passive experience of
bei ng pressed by some weight from out-
side or possibly one' s own weight, "gi r na"
seems to be something more spont aneous.
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It might therefore be considered as some-
thing more active. On the other hand,
however, an object will fall, if it does not
resist the forces that draw it down, while
"depression'' may indicate that the pres-
sure from above has to be exercised against
resistance. To conclude from this, that
Indian patients, who, according to usage of
language "let themselves fall", might be
more prone to fall into depression than the
Western patient, who has to be pressed
down against resistance, would however be
wrong. When last year, in a lecture given
at the University Clinic of Psychiatry at
Basel (12), I reported about some statisti-
cal figures of our Center, I was told that
the distribution of cases amongst the vari-
ous diagnostic categories was remarkably
similar to that registered in Swiss clinics.
As to Indian figures, I could not find any
material up to now, which would have al-
lowed valid comparison with our particular
case-material. (I found some figures for
Ranehi Mental Hospital : For 194S''49 the
figure for manic-depressive psychosis is
4.4 %. for 1949/50 it is 6.3',, , for 1950/51
it is 7. 8' . ) (13) 1 would be interested in
getting figures from other clinics with in-
and out -pateints. It goes without saying,
that our figures can in no way be utilized
to gain some idea about the incidence of
manic-depressive illness in the total popu-
Our own figures are taken from 1190 pa-
tients examined between April 19.56 and
June 1960. Of these patients, 6.2%, i.e.
74, were diagnosed as suffering from either
a manic or a depressive phase of cyclic
psychosis, while, just to give one figure for
comparison, 27.6' '<of the total figure were
patients with schizophrenic disorders. I
have not calculated any total figures yet
for the other diagnostic categories. I can,
however, say that during the last 4 years
of Psychiatry [ Vol. Ill No. 1
tbese two figures, for manic-depressive psy-
chosis and schizophrenia, have remained
fairly constant, while the figure for neuro-
tics for instance has shown much greater
fluctuations (between 23.9% and 42. 2' . ).
Of the 74 patients belonging to the
manic-depressive group, 53 were first exa-
mined during a phase of depression, 21
during a phase of mania or hypoinania. Of
these ,53 depressive patients, however, 5%
of the men and 30' . of the women also
had gone through manic phases at some
time or other, while 24' . of the patients
first observed in mania also had experienc-
ed depressions. It may be interesting to
compare this incidence of manic phases
with a figure given by Kielholz, (1)
who found that 34' < of his depressive pa-
tients had also gone through manic phases.
My closer investigations only concern 50
of those patients who were seen during a
definite depressive phase. 20 of them are
men, 30 women. (This ratio of 60' . wo-
men approximates to that named by
Bleuler (14) which is 70% women
against 30% men). Going through the
case-histories, I tried to list the contents of
the patients' depressive thoughts according
to different headings. In Europe, we
usually distinguish three main categories
of depressive ideas; hypochondriac ones,
concerning the physical integrity of the pa-
tient; ideas of impoverishment, concerning
the material circumstances; ideas ol guilt
and sinfulness, pertaining to the moral and
religious sphere. In addition, of course,
one finds suicidal ideas, doubts about reli-
gion and paranoid elaborations. When
trying to group the ideas expressed by my
Indian patients, I found it convenient to
establish the following categories, which I
shall indicate in the order of their fre-
quency (See Table 1).
Indian Journal
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Janury \?6l \ Contents of Depressive Ideas in Indian Patients Hoch
All Patients (50)
50j j
Al l Men (20)
Al l Women (30}
m 50* <
Hindu Men (18)
Hindu Women (25)
50 A

English spea-
king , educated
JVcrnacular edu-
c a t i o n , citjr
Li t t l e or no edu-
cat i on, vi l l age
Table 1 : Shows the contents of depressive ideas in order of their frequency. In the separate graphs for Men and
Women and Hindu Men and Hindu Women, the educational status is indicated by different marking,
as indicated above. The 50% line refers to the total number of patients in each group.
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34 Indian Journal of Psychiatry [ Vol. Ill No. 1
78% of the patients had ideas concern-
ing the body and its functions. Some of
these of course merely represented a more
marked or even exaggerated concern about
the basic vital symptoms, such as sleep-
lessness, lack of appetite, weakness; but
most of the patients counted in this group
expressed definite hypochondriac ideas.
58% of the patients were worried, in some
way or other, about the welfare of their
family-members. This, perhaps, is a fea-
ture which one would not expect with such
regularity in Western patients. 38% of the
patients, mainly the more educated ones,
felt uneasy about their work. 36% of the
patients admitted suicidal ideas; some of
them had even been saved from attempted
suicide. Fairly close to the frequency of
suicidal ideas come the feelings of guilt
and sinfulness with 32%. 20% of the pa-
tients were preoccupied about their mental
functions, either fearing that they might
go mad or worrying about lack of con-
centration. In 18% of the cases we found
some paranoid elaborations, and in an
equal percentage of cases the patients felt
that their religious faith had been destroy-
ed or weakened by the illness. Definite
ideas of impoverishment or worrying about
material possessions were only present in
16% of the cases. "-
One must of course add that the ideas
we were able to list in this order are only
the ones which our patients either voiced
spontaneously, or which they admitted on
being asked. It is very probable that
shame, embarrassment, fear of violating
convention, may have prevented many pa-
tiepts from exposing their more secret
;l\^prehensions and doubts. Some of the
patients only revealed their most upsetting
thoughts after several interviews or even
only when the depression was lifting or
practically overcome. Much may also de-
pend on the way one asks the patient about
his complaints. Recently, since I had
started on this study, I have taken more
care to ask depressive patients about the
various spheres their thoughts might have
turned to. Their response to my inquiries
has given me the impression that guilt-
feelings, for instance, might be far more
frequent than one would conclude from
the patients' spontaneous accounts.
Though the results of splitting such a
small number of patients into even smaller
groups may be rather doubtful, I attempt-
ed to investigate my figures with regard to
sex, age, educational status, religion and
If we keep in mind the sequence of the
depressive themes in order of frequency,
our group of 20 men mainly deviates from
the general pattern by a predominance of
concern about material possessions over
paranoid ideas. The other themes keep
their place, though not quite with the same
proportions. In more than 50% of the
men, preoccupations about body, family,
work and suicide are present, whereas the
theme of guilt follows with a greater dis-
tance than in the whole group, keeping
closer to the figures for mind, religion,
paranoid and possessions. If we want to
adjust the sequence so as to reflect the
frequency of the different themes in the 30
female patients observed, we find again
that the curve follows the general pattern,
as far as body and family are concerned.
The only preoccupation, however, which is
present in more than 50% of the female
patients, is that about physical integrity.
On the whole we find amongst women
fewer themes associated in one and the
same individaul than amongst the men.
There are quite a number of cases amongst
the women, in whom, apart from the vital
syndrome, depressive preoccupation only
concerns one single sphere of life. The
third place, after body and family, is taken
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January 1961] Contents oj Depressive Ideas in Indian PatientsHoch 35
by the guilt-feelings; then come work and
suicide in the same sequence as amongst
the men. The order of the remaining
themes differs completely from the pattern
amongst men: paranoid elaborations occur
as frequently as ideas of suicide and al-
most as frequently as those concerning re-
ligious faith, whereas worries about mate-
rial possessions take the same place as the
fear of losing one's mind. (See Table 1).
It is, however, very doubtful, whether
the variations in the two curves for the
male and female patients really represent
a true pattern of sex difference. If we
consider the educational status of our
patients, we find that all of the men ex-
cept one had had an education which en-
abled them to express themselves freely
in English. Amongst the women, only
one third had had an approximately equi-
valent education. Of the 20 remaining
female patients, 12 were from cities with
some vernacular education, 8 were village
women with little or no education. While
depressive preoccupation with body and
family occurs in almost equal parts in all
these 3 categories of women, again prov-
ing the high degree of universality of
these two themes, concern about work and
balance of mind is found only in the more
educated groups. The themes of suicide
and guilt are present in fairly equal pro-
portions in all three educational groups,
while paranoid elaborations and worry
about material possessions are slightly
more pronouned in the group of village
women, religious ideas, on the other hand,
more in the highly educated group.
Again, however, these differences might
not be quite typical for these educational
groups, at least not amongst the women.
We have to consider that 40% of the most
educated women are Christians, 2 of them
Anglo-Indians. This factor may signifi-
cantly change the picture. If we only
consider the Hindu women, leaving out
the 4 educated Christians and one primi-
tive Muslim woman, paranoid ideas take
the same place as guilt-feelings, followed
closely by ideas concerning work and sui-
cide, while doubt about religious faith
comes last, leaving preoccupation with
mind and possessions in an equal position.
Amongst the male patients there was only
one Christian and one Muslim. Leaving
out these two patients, the Hindu group
does not show any essential deviation
from the total of men. (See table 1)
While mentioning religion, it may be in-
teresting to note that, though the percent-
age of Christians and Sikhs in the manic-de-
pressive group corresponds quite closely to
their proportion amongst the total number
of our patients, the share of Hindus
amongst the manic-depressive patients
with 81' < is higher than the percentage of
Hindus amongst the total of patients, which
is 69. 1%. The proportion of Muslims
amongst the manic-depressive group is
with 6.7% considerably lower than the
Muslim share in the total of patients,
which is 17. 1%. If we count depressions
only, the Muslim share is only 3. 8%,
which is only one quarter of the percent-
age of Muslims in the total case-material.
An attempt at dividing the patients into-
two groups according to age: one of the
patients below age of 35, one of the pa-
tients above 35 years, shows up some dif-
ferences. It is however, doubtful, whether
they are significant. While all of the men
below 35 thought of suicide and 50 %> of
them expressed guilt-feelings, less than
half of the men above 35 seemed to con-
sider these possibilities. In both men and
women, paranoid ideas and religious
doubts were definitely more frequent in
the older age-group, while guilt-feelings
and apprehension about mental balance
seem to worry more the members of the
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Indian Journal of Psychiatry
[ Vol. Ill No. 1
younger generation. As, in the female
group, more of the highly educated pa-
tients are to be found amongst those above
35 years, these latter figures might of
course point to a greater self-awareness
amongst the younger generation, quite
indepedently of educational status. We
might, in this case be allowed to conclude
that the growth of consciousness of self,
stimulated through the recent cultural
changes in this country, have by now led
the younger generation to a stage, from
which Western patients, according to Lenz
and others emoted by him, are already
departing. In the process of becoming
conscious of himself as a separate, respon-
sible unit man, when falling into depres-
sion, first seems to have to turn inward in
ideas of self-incrimination and self-des-
truction. Then, however, if we are to ac-
cept the Western figures given by Lenz,
which indicate a decrease of suicidal ideas
and guilt-feelings during the past 50 years,
If a person becomes more jittery and
anxious after taking tranquilizers, the drug
may have worked too well and on the
wrong system.
In a study of 4,000 patients taking tran-
quilizers, Dr. Frank J. Ayd, Jr., chief of
psychiatry at Franklin Square Hospital in
Baltimore, Md., U.S.A., found 500 patients
with symptoms ranging from muscular
weakness and anxiety to laboured breath-
ing and grotesque body contortions.
Most of the blame fell on the phenothia-
zine group of tranquilizers, Dr. Ayd re-
it looks, as if man again departed from
this pattern, perhaps once more to turn his
aggressions and aspirations outward. It
may, of course, not be permissible to draw
such conclusions about the changing con-
tents of depressive ideas from a mere com-
parison between patients of two different
age-groups. The process of ageing it-
self, no matter during which epoch and
under what "spirit of the age", is quite
likely to change the character of depres-
sive ideas too. But, in that case, would
one not rather expect an increasing inter-
nalization with increasing age, particularly
in view of the Hindu tradition of the 4
Ashramas? In our case-material, however,
the depressive manifestations that are most
definitely turned inward, i.e. those con-
cerning guilt, suicide and mental balance,
are all present in a distinctly higher per-
centage amongst the younger patients.
(To be continued)
ports in Psychosomatics, the journal of the
Academy of Psychosomatic Medicine.
These drugs can distort or interfere with
normal muscular activities by disrupting
the system which co-ordinates movement.
Although such symptoms may occur at
any age, the changes are greater as age
increases. The reactions can be controlled
by giving Akineton, a new drug developed
for treatment of Parkinson's disease, Dr.
Ayd said.
Science Digest-Oct. 1960. Page 26.
> *
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