psychiatry. Although the grouping of such apparently different and even opposite pathological states as melancholic depression and mania may appear unreasonable on superficial consideration, its legitimacy is nevertheless incontestable and is based upon two principal arguments:

(1) The existence of certain fundamental symptoms common to all forms, manic, depressed, or mixed.

(2) The alternation, regular or not, as the case may be, of the phenomena of excitement and of depression in the same subject.

(1) Fundamental symptoms. The symptoms of manic depressive insanity can be readily divided into two groups.

The first group comprises all the morbid phenomena dependent upon psychic paralysis, namely: (a) weakening of attention; (b) sluggish formation of associations of ideas; (c) insufficiency of perception; (d) pathological indifference.

These symptoms of psychic paralysis are especially prominent in the depressed type. But in mania, though usually marked by phenomena of exaggeration of the mental automatism (flight of ideas, motor excitement), they are, nevertheless, also present, as can be readily shown by a careful examination.

Let us consider these symptoms individually.

(a) Weakening of attention. — Abnormal mobility of attention is one of the fundamental symptoms of mania. Yet, as shown in the first part of the book, this is but a manifestation of weakening of attention.

(b) Sluggish formation of associations of ideas. Kraepelin1 and his pupils have shown by means of psychometry that the acceleration of mental processes in mania affects only the automatic processes, voluntary associations of ideas being actually retarded, just as they are in the depressed states.

(c) Insufficiency of perception. - Perception of the external world is inaccurate in depression as well as in mania; but while in the former case the perceptions are often incomplete and are manifested clinically by uncertainty, in the latter case automatic associations occur in the place of missing normal ones and give rise to false perceptions or illusions. Neither the melancholiac nor the maniac perceives the phenomena of the external world in their true aspect, but the one remains in doubt while the other affirms errors.

(d) Pathological indifference also clearly exists in the maniac as well as in the melancholiac. To be convinced of this, it suffices but to recall the perfect serenity with which the maniac receives news of a misfortune in his family which, in the normal state, would profoundly distress him.

Psychic inhibition expressed by the above four symptoms is, therefore, the fundamental and constant disorder which is the common basis of the diverse clinical types of attacks of manic depressive insanity.

1 Psychiatrie, 7th edition, Vol. II, p. 504. On the subject of measurement of the rapidity of the associations in the insane, particularly in circular insanity, see also Ziehen's contribution in Neurol. Centralbl., 1896.

The symptoms of the second group are dependent, not upon psychic inhibition, but upon exaltation of the mental automatism, which so often accompanies it. The principal symptoms of this group are: (a) Flight of ideas; (b) irritability; (c) impulsive reactions; (d) delusions and psycho-sensory disorders; (e) fixed ideas and, occasionally, imperative ideas.

All these morbid phenomena are incidental. Their presence or absence modifies the aspect but not the nature of the attack. Some appear with equal frequency in mania and in melancholia; namely, delusions and hallucinations. Others are, on the contrary, peculiar either to the one or to the other of these states: flight of ideas, irritability, impulsiveness to mania, fixed ideas to melancholia. But there is no absolute rule in this respect; we meet with depressed cases with flight of ideas, and with cases of mania in which the delusions are more or less fixed.

(2) Alternation of excitement and depression in the same subject. The close relationship existing between states of depression and maniacal states becomes still more evident when; instead of considering a single attack, we make a study of all the attacks of one individual. First of all, it is extremely rare for a patient to have only one attack of mania or of melancholic depression in his life. Thus isolated and non-recurring mania or melancholic depression is almost eliminated. In some cases, it is true, the attacks are always manic, while in some others they are always depressed. These two groups, apparently separated by an unfathomable

abyss, are in reality connected by a much larger group of double, alternating, circular, and irregular forms, which establish an insensible transition from the one to the other. Moreover, a close study of cases shows that the majority of attacks presenting the manic type or the depressed type are in reality attacks of double form. In fact, on careful inquiry we find that almost constantly maniacal symptoms are preceded by a prodromal period characterized by more or less marked depression; again, we often find an attack of depression to be followed by a state of excitement which cannot be attributed to any known cause, not even to the patient's prospect of returning to his usual mode of life in the near future. Thus all attacks of mania and of melancholic depression contain in a rudimentary form the elements of excitement and of depression. Circular insanity thus becomes the prototype from which the other types are derived.

The above considerations show us that, in spite of the apparent diversity of the symptoms, mania, melancholic depression, and their various combinations are not to be considered, as heretofore, as different morbid entities, and that the following conclusion arrived at by Kraepelin is perfectly justifiable:

"The diverse forms which have been described are but different manifestations of one and the same fundamental pathological process, equivalents, like the many forms assumed by epileptic paroxysms. "1

1 Kraepelin. Psychiatrie, 7th edition, Vol. II, p. 558.

Treatment. For the treatment of the symptoms which may arise in the different phases of manic depressive insanity the reader is referred to the general discussion of the treatment of insanity in the first part of this book. As to the question of prevention of recurrency an important point to bear in mind is the necessity of insisting upon absolute abstinence from all forms of alcoholic beverages. A single drink of whiskey has been known to act as the undoubted cause of an attack in a manic depressive individual, and there are some cases in which most of the attacks are attributable to overindulgence in alcohol.

An attempt has been made by Kohn to prevent the recurrency of attacks in cases in which the outbreaks are brief and frequent and occur with such regularity that the date of their onset can be predicted with more or less accuracy. In such cases, beginning several days before the expected attack, the patient is given from 12 to 15 grams of sodium bromide daily until the "danger period" is over, when the dose is gradually diminished and the drug finally discontinued. It seems in some cases possible to prevent the outbreaks of excitement by this method of treatment.

§ 5. CHRONIC MANIA.

The diagnosis of chronic mania was but a few years ago one of the most common in psychiatry. To-day there can be no doubt that many cases formerly thus labeled belong to excited forms of dementia præcox, particularly catatonic excitements: many, but not all. Chronic mania, though rare,