Manic-depressive psychoses are manifested in attacks presenting a double characteristic: a tendency toward recovery without mental deterioration and a tendency toward recurrency. From a symptomatic standpoint the attacks are of three types, which we shall describe successively:

Manic type;

Depressed type;

Mixed types.

Sec. 1. Manic Type

Mania presents itself in three principal forms: simple mania, delusional mania, and confused mania. We shall first study simple mania, which, more clearly than the other forms, exhibits the following four fundamental symptoms of the disease:

Flight of ideas;

Morbid euphoria and irritability;

Impulsive character of the reactions;

Motor excitement.

Simple Mania. Prodromata

The phenomena of manic excitement are almost constantly preceded by a period of depression characterized by diminution of psychic activity, which sometimes amounts to a veritable melancholic state. Later on we shall see the importance of this prodromal period as an argument for the unity of manic-depressive psychoses.

1 Kraepelin. Lehrbuch der Psychiatrie, Vol. II. - Weygandt. Ueber das manisch-depressives Irresein. Berlin, klin. Woch., 1901, Nos. 4 and 5.

External Aspect

The face is flushed, the eyes brilliant, the expression happy and animated. The manner and gestures indicate a state of ease contrasting often with the usual timidity of the patient. The dress is showy, ridiculous, and ornamented with gaudy trinkets; the clothes are in disorder, perhaps put on inside out. In women a bodice excessively decollete and the skirt raised too high show also the erotic tendencies.

Intellectual Disorders

Lucidity is perfect, orientation and memory are intact.

The attention, very mobile, is distracted by all external impressions.

Associations of ideas, uncontrolled, are formed at random from similarities of sound, superficial resemblances, coexistences in time and space, etc. Flight of ideas is here encountered in its typical form.

These two symptoms, mobility of attention (distract-ibility) and flight of ideas, are, as we have already seen, an expression of weakening of normal psychic activity and predominance of mental automatism. Under these conditions the capacity for intellectual labor is diminished.

The judgment, which is largely dependent upon associations of ideas, is always profoundly disordered. Though occasionally the patient surprises one by the accuracy of his observation, it is always the result of a sort of automatic appreciation bearing upon some isolated fact. But since judgment necessitates the systematic grouping of a very considerable number of ideas, it is here absent or at least impaired. A maniac who notices some slight defect in the dress of the examiner is incapable of appreciating the importance of an event or of an act.

Affective Disorders

These consist in morbid euphoria and irritability.

The euphoria is often very marked. Many patients after recovery declare that they had never felt so happy as they did during the attack. The maniac is pleased with everything, and the contrast is particularly striking when the excitement follows a period of depression (attack of doable form). The most imperturbable optimism replaces the pessimism of other days. Of disease insight there is no question at all; the subject "never before felt so well"; if he is "somewhat nervous" the fault is with his relatives, the physicians, or the nurses, who constantly interfere with him. With his intelligence and activity he could "easily conduct important and gigantic enterprises." If he were allowed liberty of action, he would show everybody what he is capable of.

Sad impressions are dismissed with a vague remark or a joke. A maniac, reminded of the loss of his property in a fire (which incidentally was the cause of his attack), replied laughingly: "Money does not bring happiness, and besides I shall have earned twice as much six months from now."

This optimism, however, is never so absurd as that of general paralytics or senile dements. Dumas cites the case of a general paralytic who, reminded of the recent death of his two little daughters, replied: "Well, well! I shall resuscitate them." A maniac would never have given such an answer.

The irritability is evident in the violent outbursts of anger which occur on the slightest provocation. The maniac will bear no contradiction and will accept no suggestions.

The moral sense is always diminished; the sense of propriety is greatly affected. The maniac is cynical, dishonest, and mischievous. "He lies, cheats, and steals without the least scruple. He allows himself anything that in others he would condemn" (Wernicke). Quite frequently he will tease and mock others. If in the midst of his rambling speech some pointed or amusing remark occurs, it is always at the expense of others.

Erotic tendencies form an integral part of the picture: the patients abandon themselves to them without shame. Men previously exemplary in habits go around with prostitutes. Young girls, normally very reserved in their manner, offer themselves to everybody.

One frequently sees maniacs indulging in alcoholic excesses.

The patient is incapable of appreciating the significance of his acts either before or after they are accomplished. The most deprecable acts are displayed with complacency and become the objects of cynical pleasantries; compunction and scruples are absent.

Reactions

The elements of manic excitement consist in: imperative pressure of movement, abnormal rapidity of reactions, and impulsive character of the acts.

Manic excitement always has a psychic origin (Wernicke); the acts, though impulsive, are dependent upon an appreciable cause and have a definite purpose.

This excitement often assumes the aspect of morbid activity which, lacking in logical sequence, remains unproductive when it does not become harmful. The maniac every instant leaves one task to begin another, or undertakes tasks for which he possesses neither the necessary aptitude nor the qualifications. A farmer, fifty years of age and scarcely able to read or write, wanted to undertake the study of Hebrew "to unite the Jews and the Protestants."

The maniac is strongly inclined to intrude into the affairs of others, causing, as might be expected, much trouble. He offers his advice and assistance to everybody. In the hospital he accompanies the physician on his rounds, makes diagnoses, and prescribes treatment. Often he tries to assist the nurses, who find it very difficult to moderate his zeal.

In the more marked degrees the excitement leads the patient to many eccentricities. He removes his clothing, replaces it; executes pirouettes and dangerous leaps; sings obscene songs; performs grimaces and contortions for the amusement of his spectators; and frequently annoys others in a thousand ways.

The conversation is animated, strewn with eccentric expressions, strange words and puns. The language may be either profane and obscene or marked by a labored refinement. The tone may be jocose or solemn, accompanied by the gestures of a gamin or, on the contrary, by those of a commander or a preacher. There is often veritable logorrhcea.

The writing presents analogous characteristics. Volubility and prolixity are manifested by whole pages scribbled within a few minutes. The lines cross each other in every direction, the letters are large in size, and capitals and flourishes are abundant. Often there is manic graphorrhea, analogous to the manic logorrhcea referred to above.

The discourse is conducted at random: reflections upon questions of transcendental philosophy as well as upon those of dress or cooking; slander and intimate confidences, extravagant projects, and erotic proposals. The maniac conceals nothing.

Physical Symptoms

We find in mania the physical symptoms which, we have already seen, are associated with morbid euphoria: the general nutrition and the peripheral circulation are active, the pulse is full and rapid, respiration is deep and accelerated, the appetite is good, and the weight increases.

Sleep is diminished, occasionally altogether absent; but in spite of the insomnia the patient experiences no fatigue.

Often in women the menses are suspended, and their return indicates the approach of recovery. When they persist through the attack their appearance is likely to provoke a recrudescence of excitement.