THE MANIC-DEPRESSIVE PSYCHOSES
The manic-depressive psychoses as first described by Kraepelin are
of comparatively recent origin. The history of the clinical entities
included in this new grouping, however, may be easily traced back to
the earliest days of psychiatry. Although these terms were not used
perhaps as they came to be later, mania and melancholia were, as has
already been shown, known in the Hippocratic era, over four hundred
years before the time of Christ. They were referred to again in the
works of Aretaeus in the first century A. D. and were recognized by
Celsus, Caelius Aurelianus and Galen. Daniel Sennert[267] of Wittenberg
(1572-1637) defined melancholia as a "delirium or deprival of
imagination and reason, without fever, with fear and sadness, arising
from dark and melancholy animal spirits, and occasioning corresponding
phantoms." Mania he described as a "delirium or deprival of imagination
and reason without fear, but, on the contrary, with audacity, temerity,
anger, and ferocity, without fever, arising from a fervent and fiery
disposition."
Sydenham[268] recommended bleeding, followed by purgation, as the
treatment indicated for mania:—"Thus the humours, which in mania would
invade the citadel of the brain, are gradually drawn off towards the
lower parts, a fresh bias being given to them."
Thomas Willis[269] made some very significant references to the
relation existing between mania and melancholia, in the seventeenth
century:—"After melancholia we have to treat of mania, which has so
many relations to the former, that the two disorders often follow
each other, the former changing into the latter, and inversely. The
melancholic diathesis, indeed, carried to its highest degree, causes
frenzy, and frenzy subsiding changes frequently into melancholia
(atrabiliar diathesis). These two disorders, like fire and smoke, often
mask and replace each other, and if we may say that in melancholia
the brain and the animal spirit are obscured by smoke and black
darkness, mania may be compared to a great fire destined to disperse
and to illuminate it." Morgagni,[270] "the father of pathology," also
saw a close relation between these two conditions as is shown by the
following quotation from his "De Sedibus et Causis Morborum;" etc.,
in 1761. "Melancholia," he says, "is so nearly allied to mania, that
the diseases frequently alternate, and pass into one another; so that
you frequently see physicians in doubt whether they should call a
patient a melancholiac or a maniac, taciturnity and fear alternating
with audacity in the same patient; on which account, when I have
asked under what kind of delirium the insane persons have laboured
whose heads I was about to dissect, I have had the more patience
in receiving answers which were frequently ambiguous and sometimes
antagonistic to each other, yet, which were, perhaps, true in the long
course of the insanity." Flemming[271] in 1844 described a "dysthymia
atra" (melancholia), a "dysthymia candida" (cheerful dysthymia) or
"melancholia hilaris" characterized by elation with playfulness and a
"tendency to see everything in the most pleasant and cheerful light" as
well as a "dysthymia mutabilis," an alternating variety involving both
of the above forms. He also spoke of a "dysthymia sparsa" (apathica)
or "melancholia attonita," and a "vesania maniaca" or mania which
he divided into the acute, delirious, alcoholic, affective, and
puerperal types, together with an "occult amentia" embracing all of
these forms. Griesinger[272] in 1845 called attention to the fact
that "the transition of melancholia into mania, and the alternation
of these two forms, are very common." In 1851 Falret, senior, first
described circular insanity in his lectures at the Salpêtrière, quoted
by Tuke[273] as follows:—"We have also to mention another case of
intermittence observed between the periods of remission and excitement
in the forme circulaire des maladies mentales." "It is a special
form which we call 'circular' and which consists, not as has been
frequently said, in a change of mania into melancholia separated by a
more or less prolonged lucid interval, but in the change from maniacal
excitement—simple overactivity of all the faculties—into mental
torpor."
In 1854 at the Academy of Medicine in Paris Falret presented his
"Mémoire sur la folie circulaire, forme de maladie mentale caractérisée
par la reproduction successive et régulière de l'état maniaque, de
l'état mélancolique, et d'un intervalle lucide plus ou moins prolongé."
In the same year Baillarger described his "Folie à double forme,"
summarized by him in a Bulletin of the Academy of Medicine as follows:—
"(1) Besides monomania, melancholia, and mania, there exists a
special form of insanity characterized by two regular periods, one of
depression, the other of excitement.
(2) This form of insanity: (1) presents itself in isolated attacks;
(2) reproduces itself in intermissions; (3) the attacks may follow
each other without interruption.
(3) The duration of the attacks varies from two days to one year.
(4) When the attacks are short, the transition from the first to the
second period takes place suddenly, and generally during sleep. It
takes place slowly and gradually when the attacks are prolonged.
(5) In the latter case, the patients seem to enter into a state of
convalescence at the end of the first period, but this return to
health is incomplete; after a fortnight, a month, six weeks or more,
the second period breaks out."
This was described as "Folie à double phase" by Bellod, "Folie à formes
alternés" by Delaye, "Délire à formes alternés" by Legrand du Saulle,
"Die cyclische Psychose" by Ludwig Kirn and "Das circuläre Irresein" by
Krafft-Ebing.
At a meeting of the American Association in 1886 the classification
of the British Medico-Psychological Association was adopted with the
omission of moral insanity and the addition of toxic insanity. This
included the following types of mania:—Recent, chronic, recurrent,
à potu, puerperal and senile, and classified melancholia as recent,
chronic, recurrent, puerperal and senile. In his "Clinical Lectures
on Mental Disease" Clouston in 1898 described eight varieties of
melancholia and six of mania, not including alternating forms. Kahlbaum
in 1882, reverting apparently to the phraseology of Flemming, spoke
of dysthymia, hyperthymia and mixed or circular forms—cyclothymia.
Many of the conditions afterwards classified under dementia praecox he
described as "vesania typica."
It will be observed that, based somewhat on the conceptions of
Griesinger, states of mental excitement were generally characterized
as mania and all depressions as melancholia. As has been shown, the
view that there was some definite relation between these two conditions
had been gaining ground for many years and culminated in the "circular
insanity" concept. In the meanwhile over fifty varieties of mania and
thirty forms of melancholia were described by various authors. Aside
from an emotional exaltation and increased psychomotor activity, few
definite characteristics were insisted upon in a consideration of
mania. There was almost invariably a disturbance of sleep but always
with a sense of well-being and no feeling of exhaustion. The milder
type of the disease was often referred to as "hypomania." In the more
severe forms varying grades of violence developed. There was at times
a clouding of the sensorium, a temporary appearance of hallucinations
of sight and hearing, delusions of a persecutory or grandiose nature
and incoherence of speech. Impulsive acts occasionally were noted
during the height of the excitement. These attacks were frequently
preceded by brief periods of depression. Many cases made rather early
recoveries—others, however, were spoken of as having reached a
chronic stage. Many terminated in dementia. These very often showed
stereotypies, verbigeration, impulsive excitements, mannerisms and
other symptoms now held to be characteristic of dementia praecox.
Melancholia was looked upon as including all emotional depressions
with hallucinations and delusions as the prominent symptoms. The
mental state was essentially one of sadness but with fear, agitation
and anxiety appearing at times. There was, however, no attempt at any
differentiation between psychomotor retardation with genuine depression
and apathetic states or actual mental dulness. Mutism and resistiveness
were common. A refusal of food was rather to be expected. Stuporous
states with muscular rigidity frequently occurred. Various physical
changes were described. Cyanosis of the extremities was emphasized,
with loss of weight and a lowered temperature. Many of the cases
were untidy in their habits. Brief initial attacks of excitement
were mentioned as usually ushering in the disease. These depressions
recovered, became chronic, lasting for years, or terminated in a
partial or complete dementia. These were in substance the views of
practically all of the earlier writers on insanity.
Sankey[274] in 1884 included in his idiopathic psychoses due to
pathological conditions, general paresis and "ordinary insanity." "This
is the disease which in its course presents such varying phenomena,
and has thus given occasion for multiplying the names." Prominent
in this group were the various forms of mania and melancholia and
it undoubtedly included dementia praecox. "Like other diseases it
may be artificially divided into separate stages, and this is useful
for facilitating description, but such artificial divisions must not
be looked upon as different species of disease." ... "Thus, a case
in the primary attack commences by symptoms of melancholy; these
may, when successfully treated, pass off, and the patient recover,
or the melancholic stage may be aggravated, and the patient die in
this stage;—the disease may exhibit symptoms of violence and become
acutely maniacal. There is no ground on this account to say, that the
patient has a new disease, any more than the appearance of an eruption
in an eruptive disease would be the inauguration of a different kind
of malady." Although obviously he had no idea as to the fundamental
differences between manic-depressive insanity and dementia praecox, he
unquestionably was one of the first to emphasize the fact that mania
and melancholia were often definite stages of one disease process.
In 1896 Kraepelin described melancholia as essentially an involutional
condition. Under the heading of periodic constitutional disorders he
included mania, circular and depressive forms, the mania, melancholia,
and circular insanity of other writers. Schüle[275] in 1886 described
circular, periodical and alternating psychoses. In 1894 Ziehen[276]
included in his classification under the heading of combined psychoses
a "melancholisch-maniakalisches" form in addition to mania and
melancholia, which he spoke of as affective psychoses.
It was not until 1899 that these conditions were clearly differentiated
by Kraepelin[277] and the purely emotional and recoverable forms
separated clinically from the deteriorative processes which he
has associated with dementia praecox. The former he described as
manic-depressive psychoses, which included mania, melancholia
and a majority of the circular and alternating types previously
described. This delimitation had a prognostic as well as an important
symptomatic significance. The emotional excitements were characterized
by an increased psychomotor activity, with a flight of ideas and
distractibility, usually associated with a clear sensorium. Graver
forms were, however, recognized, with a clouding of consciousness, and
disorientation, occasionally terminating in stupor. Hallucinations and
delusions when present were not prominent symptoms. The depressions
were characterized by an emotional disturbance in the form of sadness
with difficulty in thinking, associated with marked retardation in
speech and a motor inhibition. More advanced stages showed clouding,
disorientation, stuporous phases and hallucinations. He also recognized
alternating or circular as well as mixed types. The prognostic
importance of this clinical grouping was the tendency towards a
complete recovery from the individual attack, with, however, an
extreme probability later of a recurrence, the subsequent attacks
assuming either form of the disease. As a rule Kraepelin found that the
unfavorable types formerly included in the manias and melancholiac,
together with the hebephrenia and katatonia of his fifth edition,
presented the definite characteristics of the disease which he
described as dementia praecox. His views have been modified from time
to time. For instance, he at one time excluded the involutional and
anxiety psychoses from his manic-depressive group. Later these were
included. In his last edition he has described depressed and agitated
forms of dementia praecox, which would strongly suggest that his lines
of demarcation were not so clear as he believed them to be in 1899. Of
the manic-depressive psychoses he says, "Manic depressive insanity as
described in this chapter includes on the one hand the entire domain of
the so-called periodic and circular insanities, on the other, simple
mania, the larger part of the disease process described as melancholia
and also a not inconsiderable number of cases of Amentia. Finally
we include certain mild morbid emotional states, some periodical,
some continuous, which heretofore have been looked upon either as
introductory to more severe disturbances or as belonging, without being
sharply circumscribed, to the domain of individual makeup. As years
go by I have become more and more convinced that these all represent
manifestations of one disease process." The following classification
of manic-depressive psychoses was shown in Kraepelin's last edition
(1913):—
Manic types:
Hypomania, Acute mania, Delusional and Delirious forms.
Depressive types:
Melancholia simplex, Melancholia gravis, Stupor, Paranoid, Phantastic
and Delirious forms.
Mixed types:
Depressive mania.
Excited depressions.
Mania with poverty of thought.
Manic stupor.
Depression with flight of ideas.
Retarded mania.
The mixed and atypical forms are of special importance, as they occupy
the middle ground between the classical types of manic-depressive
insanity and dementia praecox. It is here that difficulties arise and
errors in diagnosis are made. They have never received sufficient
attention until recently. In practice many of these have undoubtedly
been classed with the dementia praecox group. The first of these as
described by Kraepelin is depressive or anxious mania—characterized by
a depressive mood with anxiety and excitement and, at the same time, a
flight of ideas. The patients are distractible, observant of everything
in their surroundings, and complain that thoughts obtrude themselves
upon them. Some have a mania for scribbling. Often there are delusions
of persecution, sin, and hypochondriacal ideas. The mood is one of
anxiety or despair. Impulsive acts are occasionally observed. They are
inclined to weep, wring their hands, pull out their hair and throw
themselves on the ground.
Instead of a flight of ideas there may be poverty of thought and
retardation with excitement—an "excited depression." The patients
may be very wordy and monotonous in expression but are entirely clear
as to their surroundings. The mood is anxious and tearful, often with
delusions. There is a considerable excitement, but not of such a
stormy character as in the depressive or anxious mania.
Mania with poverty of thought, an "unproductive" form, shows a more
cheerful mood but without a flight of ideas. This form Kraepelin speaks
of as a common one. Speech is monotonous and expressionless. The
patients present almost an appearance of feeblemindedness, although
exceedingly variable and changeable. The mood is cheerful and sometimes
irritable. The excitement is shown by jumping around, making faces,
etc., but without any occupational activity. This alternates with
periods of quiet when but little is said. They show no desire to occupy
themselves in anything useful. Sudden outbursts of violence often occur.
Stuporous, almost cataleptic forms with occasional delusions of a
hypochondriacal type, fairly well oriented and with a clear sensorium,
are spoken of as "manic stupor." This is interrupted by excitement and
violence, with laughter, witty remarks and even eroticism. They often
have a clear memory of all occurrences. This stuporous type may appear
suddenly in an ordinary manic attack, or take place between excitements
and depressions.
In the course of an ordinary depression a flight of ideas may also
replace the usual retardation—"depression with flight of ideas." The
delusions are interspersed with cheerful thoughts and the patients show
certain activities and an interest in their surroundings, although
still depressed and hopeless. When they begin to talk they complain
of an inability to control their thoughts. There is an inhibition of
speech but not of thought. They may be quite prolific in writing, and
may show a characteristic flight of ideas. This condition often merges
into genuine excitement.
Kraepelin also speaks of an inhibited or "retarded mania," showing
a cheerful mood with flight of ideas and psychomotor retardation.
These eases are excited, distractible, inclined to witticisms with
"klang associations," but lie quietly in bed. He believes that there
is an inner tension manifesting itself at times in acts of violence.
Kraepelin also speaks of various other mixtures of depression,
anxiety and excitement. Specht has described an "irascible mania"
(Zorntobsucht) and Stransky a bashful mania (verschämte Manie). Dreyfus
has described a partial inhibition or retardation (partiellen Hemmung).
Hecker is responsible for a "grumbling" or faultfinding variety
of mania (nörgelnden Formen der Manie). In any event, Kraepelin's
conceptions constitute a distinct advance and have materially clarified
a much involved confusion of entities which seem to warrant complete
differentiation. His views have, of course, not been universally
accepted. The English school of psychiatrists has been slow in
expressing its approval of his theories. No textbook of late years
has appeared, however, in this country that has failed to recognize
the manic-depressive psychoses practically as Kraepelin originally
described them.
The psychological mechanisms of manic-depressive insanity have been
studied exhaustively by Karl Abraham and other psychoanalysts. He
looks upon retardation as a symbol of death and interprets it as a
defensive reaction, the patient taking refuge in a retarded state to
avoid contact with the outer world. The ideas of poverty associated
with depressions he considered as symbolic of an inability to love and
occurring in individuals who have not obtained sexual gratification in
a normal way. When repression is no longer possible mania ensues and
the patient enters upon a new existence, all instinctive inhibition
being lost. The flight of ideas he looks upon as a reestablishment
of infantilism. He suggests these views, however, as tentative. The
delusions of the manic-depressive psychoses have been interpreted as
an expression of repressed complexes. White[278] would explain these
mechanisms as follows:—"Manic-depressive psychosis is the type of
extroversion reaction. That is, the patients instead of turning within
themselves (introversion) try to escape their difficulties (conflict)
by a 'flight into reality.' This flight into reality is the manic
phase of the psychosis with its flight of ideas, distractibility and
increased psychomotor activity during which the patient seems to be
at the mercy almost of his environment having his attention diverted
by every passing stimulus. The great activity can be understood as
a defense mechanism. The patient appears, by his constant activity
to be covering every possible avenue of approach which might by any
possibility touch his sore point (complex) and so he rushes wildly
from this possible source of danger to that meanwhile keeping up a
stream of diverting activities. He is at once running away from his
conflict—into reality—and trying to adequately defend every possible
approach.... This method I have described as a 'flight into reality'
which is the characteristic of the manic phase, while the failure to
deal adequately with the difficulty is manifested by the depression
of the depressive phase. In the depression the defenses have broken
down and the patient is overwhelmed by a sense of his moral turpitude
(self-accusatory delusions). This sense of being sinful is the
conscious appreciation of tendencies which should have been left behind
to become a part of the historical past (the unconscious) in the course
of the development of the psyche but which still demand expression....
The benign character of the manic-depressive group of psychoses is
explained because of their extroverted mechanism. Reality is the normal
direction for the libido and because the direction is normal they more
readily result in recovery."
The American Psychiatric Association, in its manual designed for
the assistance of hospitals for mental diseases in the compilation
of statistical data, makes the following suggestions as to the
delimitation of the manic-depressive psychoses:—
"This group comprises the essentially benign affective psychoses,
mental disorders which fundamentally are marked by emotional
oscillations and a tendency to recurrence. Various psychotic trends,
delusions, illusions and hallucinations, clouded states, stupor, etc.,
may be added. To be distinguished are:
"The _manic_ reaction with its feeling of well-being (or
irascibility), flight of ideas and over-activity.
"The _depressive_ reaction with its feeling of mental and physical
insufficiency, a despondent, sad or hopeless mood and in severe
depressions, retardation and inhibition; in some cases the mood is one
of uneasiness and anxiety, accompanied by restlessness.
"The _mixed_ reaction, a combination of manic and depressive symptoms.
"The _stupor_ reaction with its marked reduction in activity,
depression, ideas of death, and often dream-like hallucinations;
sometimes mutism, drooling and muscular symptoms suggestive of the
catatonic manifestations of dementia praecox, from which, however,
these manic-depressive stupors are to be differentiated.
"An attack is called _circular_ when, as is often the case, one phase
is followed immediately by another phase, e.g., a manic reaction
passes over into a depressive reaction or vice versa.
"Cases formerly classed as allied to manic-depressive should be placed
here rather than in the undiagnosed group.
"In the statistical reports the following should be specified:—(a)
Manic type; (b) Depressive type; (c) Stuporous type; (d) Mixed
type; (e) Circular type; (f) Other types."
Diefendorf[279] states that manic-depressive insanity comprises from
twelve to twenty per cent of the admissions to hospitals for mental
diseases. He reports defective heredity as being shown in from seventy
to eighty per cent of the cases. He also found about seventy-five per
cent of the patients suffering from this disease to be of the female
sex. Buckley[280] states that sixty per cent of the cases give positive
histories of "familial neuropathy and psychopathy." Paton[281] is of
the opinion that heredity is a factor in from eighty to ninety per
cent of all cases. Hoch has called attention to the constitutional
makeup of individuals subject to manic-depressive attacks and suggests
that they are usually of a moody, morose type, unduly optimistic or
temperamentally unstable. Kraepelin[282] found suicidal tendencies in
14.7 per cent of the female patients, and in 20.4 per cent of the men.
Nine per cent of his cases showed a manic makeup; 12.1 per cent, a
depressive temperament; 12.4 per cent were irascible or nervous; and
from three to four per cent exhibited cyclothymic tendencies. Of the
cases admitted to his clinic 48.9 per cent were depressive forms; 16.6
per cent, manic; and 34.5 per cent represented both types in various
combinations. Melancholia simplex and gravis constituted 23.5 per cent
of the simple forms, 13.5 per cent showed phantastic delusions and 6.1
per cent anxieties. Hypomanias made up four per cent, and acute mania,
9.8 per cent of the cases. Confused and stuporous states constituted
8.2 per cent and compulsions, one per cent. Lighter forms constituted
ten per cent, and more severe types, nine per cent of the admissions.
Stupors and clouding were found in 4.9 per cent and delusional states
in 4.9 per cent of the total. He quotes Walker as reporting, in a
study of 674 cases, that excitements contributed eleven per cent;
depressions, 55.7 per cent; and circular forms 33.3 per cent of the
male cases; and excitements, 6.2 per cent; depressions, 70.2 per cent;
and circular types, 23.6 per cent of the female admissions. In from
sixty to seventy per cent of Kraepelin's cases the first attack was a
depression. In two-thirds of them, after the first mild attack there
was a remission. In one-third of the cases, the depression terminated
in an excitement followed by recovery. When the disease begins with
a manic attack, two-thirds of the cases are followed by a remission.
He reports excitements with a duration of ten years and depressions
of fourteen years standing. In a study of 703 remissions he found
ninety-six lasting from ten to nineteen years; thirty-four, from
twenty to twenty-nine years; eight, from thirty to thirty-nine years;
and one of forty-four years. He is of the opinion that the length of
remission bears no relation to the duration of the attack. Of the
depressions, 167 had a remission of six years; forty-six of 2.8 years;
and twenty-seven of two years or more. Of the manic forms, fifty-three
had remissions of 3.3 years; twenty-four of 4.5 years; and twenty of
two years or more. Manic-depressive psychoses constitute from ten to
fifteen per cent of the admissions at Kraepelin's clinic. He found
hereditary taint in eighty per cent of his Heidelberg cases and quotes
Walker as reporting 73.4 per cent; Saiz 84.7 per cent; Weygandt, ninety
per cent; and Albrecht, 80.6 per cent. A history of alcoholism was
found in twenty-five per cent and syphilis in eight per cent of the
male patients.
Rehm made an interesting study of the offspring of manic-depressives.
Of forty-four children in nineteen families, fifty-two per cent showed
evidences of psychic degenerations, twenty-nine per cent of which
consisted in an abnormal emotional makeup usually of the depressive
types. In 157 cases from fifty-nine families, Bergamasco found that 109
showed manic-depressive psychoses. Kraepelin noted that the highest
percentage of the first attacks occurred between the ages of fifteen
and twenty. Reiss made a very significant analysis of the various
forms of the disease manifested by individuals possessing definite
predisposition. Thus, of the cases with a depressive makeup 64.2 per
cent had depressive attacks, 8.3 per cent, manic, and 27.5 per cent,
combined forms. Of those with manic temperaments, 35.6 per cent had
depressive attacks, 23.3 per cent, manic, and 41.1 per cent, combined
forms. Of the irritable individuals, 45.5 per cent had depressive
attacks, 24.4 per cent, manic, and 30.1 per cent, combined forms. Of
the cyclothymic persons, 35.3 per cent had depressions, 11.7 per cent,
excitements, and fifty-three per cent, combined forms.
An analysis of the number of cases of manic-depressive insanity
admitted to American institutions is exceedingly interesting in
view of the opinions expressed by Kraepelin. From 1912 to 1919
there were 49,640 first admissions to the thirteen New York state
hospitals. Of these, 7,499, or 15.1 per cent, were diagnosed as having
manic-depressive psychoses or allied conditions. During the years
1918 and 1919, when the Association's classification was officially
used throughout, the percentage of manic-depressive psychoses was
14.57. In the fourteen state hospitals of Massachusetts in 1919 there
were 3,011 first admissions. Two hundred and eighty-three, or 9.39
per cent, of these were manic-depressive psychoses. In twenty-one
state hospitals in fourteen other states, practically all in 1917,
1918 and 1919, there were 18,336 first admissions. Of these 3,409,
or 18.59 per cent, were cases of manic-depressive insanity. Thus, of
the 70,987 first admissions reported from forty-eight hospitals in
sixteen different states there were 11,191 cases of manic-depressive
insanity, a percentage of 15.76. This may probably be looked upon as
fairly representative of the incidence of manic-depressive psychoses in
American institutions.
When it comes to an analysis of the various forms of manic-depressive
psychoses reported, the indications are not so clear. In New York
during 1918 and 1919 there were 1,980 cases distributed as follows:—
_Type_ _Number_ _Percentage_
Manic 905 45.71
Depressive 729 36.82
Stuporous 53 2.68
Mixed 245 12.37
Circular 48 2.42
During the eight-year period referred to above in the New York
hospitals there were 6,091 cases of manic-depressive and allied
conditions, classified as follows:—
_Type_ _Number_ _Percentage_
Manic 2952 48.46
Depressive 2014 33.06
Stuporous 76 1.24
Mixed 773 12.69
Circular 199 3.26
The fourteen Massachusetts hospitals reported 672 cases in 1917 and
1918, classified as follows:—
_Type_ _Number_ _Percentage_
Manic 222 33.03
Depressive 373 55.50
Stuporous 4 .59
Mixed 66 9.82
Circular 7 1.04
In the twenty-one hospitals in fourteen other states there were 3,409
cases of manic-depressive psychoses as follows:—
_Type_ _Number_ _Percentage_
Manic 1401 41.09
Depressive 1365 46.04
Stuporous 62 1.82
Mixed 228 6.69
Circular 94 2.76
The total from all of these institutions, of 12,152 cases, was
classified as follows:—
_Type_ _Number_ _Percentage_
Manic 5480 45.09
Depressive 4481 36.87
Stuporous 195 1.60
Mixed 1312 10.79
Circular 348 2.87
It will be noted that manic cases are more common than the depressive
in New York, the number of the former being fifteen per cent greater
than the latter. In Massachusetts the number of depressive forms is
twenty-two per cent higher than the manic. In the other states the
depressive types are less than five per cent higher than the manic.
In all institutions the mixed forms are more common than the circular
or stuporous. The stuporous forms constitute the smallest percentage
reported in all hospitals, except in 1918 and 1919 in New York. We
would be warranted, apparently, in the conclusion that in this country
manic forms are the more common, the depressive being second in
frequency, followed by the circular and stuporous types in the order
mentioned.
The statement is, I think, also warranted that there is a considerable
difference of opinion as to the classification of the different forms
of manic-depressive insanity and that diagnostic procedure is far
from being standardized. Many of these discrepancies are doubtless
due to difficulties in differentiating between certain cases of
manic-depressive psychoses and dementia praecox. The hospitals
reporting lower percentages of the former usually show a much higher
rate of the latter. Certainly there is room for an honest difference
of opinion in many instances. It must be admitted, moreover, that our
fundamental conceptions of these two great groups do not permit of a
hard and fast line of demarcation between them in all cases.