"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:—