The fundamental symptoms of the depressed type are:

Psychic inhibition;

A painful emotional state associated with indifference;

Aboulia.

As in the case of mania, we distinguish here three forms: simple, delusional, and stuporous depression.

Simple Depression. Onset

Usually insidious, preceded by ill-defined prodromata, such as general tired feeling, insomnia, anorexia, discouragement.

The external aspect of the patient is one of sadness, listlessness, and indifference. The features are drawn out, head bowed down upon the chest, arms hanging inertly at the sides or resting upon the knees. The general bearing is slouchy.

Intellectual Disorders

The psychic inhibition brings about very marked weakening of attention and considerable sluggishness of the association of ideas. All intellectual exertion, such as narration of an event well known to the patient or a small calculation, is impossible or can be accomplished only after repeated and painful efforts. Though lucidity is intact, perceptions are incomplete, uncertain and often inaccurate. Everything appears to the patient strange or unrecognizable: persons, objects, and even his own body. Here we have a condition bordering upon a delusional state. Another step and we have illusions and hypochondriacal ideas.

The disorders of judgment are less marked than in mania. The patient is quite frequently conscious of his condition to some extent. He feels that he is changed, ill, and it seems to him that his mind is paralyzed.

Affective Disorders

The mood is sad, gloomy, pessimistic. The patient emits monotonous groans. While the maniac brings disorder into the hospital, the melancho-liac brings depression and gloom.

Psychic anaesthesia is usually marked, and sometimes the patient is conscious of it. He complains of having become indifferent toward everything, of experiencing no affection.

Upon this general state of depression and sadness may be engrafted a spell of anxiety, usually transient. In no case, however, is the psychic pain as intense as in involutional melancholia. The depressed phases of manic-depressive psychoses correspond to passive depression.

Disorders Of The Reactions

These all result from the marked aboulia present in such cases, which is, in its turn, a manifestation of the psychic paralysis.

The execution of the simplest act necessitates an effort so great at times that the patient gives up the attempt. Like the psychic indifference, this symptom may be a conscious one.

Combined with insufficiency of perception, aboulia brings about doubt. The patient lives in constant indecision and uncertainty.

Conversation with the patient is most unsatisfactory. Often, in spite of all persistence, the patient remains mute or. responds by an unintelligible murmur or whispering. The mental synthesis necessary for an elaboration of a response is impossible for him. In the milder cases, to some very simple questions repeated several times brief answers are obtained.

The voice is scarcely audible, the speech is indistinct. The same words are constantly reiterated, expressing doubt, indecision, sadness: "What is this? . . . What is going to happen? . . . This is frightful."

The uniting is slow; letters are poorly formed, small, disconnected.

Physical Symptoms

These have already been described in connection with morbid depression. We shall review them briefly.

The peripheral circulation is sluggish, the extremities cold and cyanotic. The pulse is small, of low tension, sometimes slowed. The heart sounds are muffled. The temperature may be subnormal.

The coated tongue, fetid breath, a sense of weight in the stomach, constipation, and anorexia reveal a poor state of the digestive functions.

Loss of weight is a constant phenomenon. The return to the normal weight always indicates the end of the attack.

Sleep is diminished, unrefreshing, disturbed by nightmares.

Often the patient complains of headache and of vague pains in the limbs.

Cutaneous sensibility is blunted.

The tendon reflexes are often diminished.

Delusional Depression

Always secondary to the emotional state, the delusions are preceded by a longer or shorter period of simple depression.

They present the usual characters of depressive ideas and assume the most varied forms: hypochondriacal ideas, ideas of humility, of self-accusation, or of ruin, fear of terrible punishment.

As in involutional melancholia, the morbid idea may occur at first in the shape of an imperative idea. The mind realizes it is false and tries to reject it. After a more or less prolonged struggle, the mind yields: the imperative idea becomes a fixed idea, and a delusional state is established.

Occasionally these delusions are quite absurd and resemble those of dementia precox. In other cases they are associated with ideas of persecution and become systematized to a certain extent, constituting a systematized delusional state of self-accusation or of persecution, as the case may be.

Hallucinations are rare. The least exceptional are those of vision.

Illusions, though less numerous than in mania, are, however, quite frequent. Following the general rule, the psycho-sensory disorders are an expression of the delusional preoccupations.

Lucidity may be transitorily affected. The usual inertia is sometimes effaced and replaced by a certain degree of excitement. In other cases it becomes, on the contrary, more marked, giving rise to transient stupor.

Depression With Stupor

This form rarely begins as such; it is usually preceded by simple or delusional depression.

The characteristic trait here is complete inertia, associated with absolute indifference to all external impressions. The physiognomy is stupid, sometimes expressing fear.

The usual physical symptoms of depression are here very pronounced.

Almost always the patient becomes negligent and filthy, wetting and soiling his bed.

In some cases may be observed a tendency to cata-leptoid attitudes.

The stupor may have one of two different origins:

(1) Psychic inhibition reaching an extreme degree of intensity suppresses all conscious and voluntary intellectual activity. The indifference is complete, the psychic pain, on the contrary, becoming nil; in fact inhibition is never perceived as a painful phenomenon unless the mind seeks to overcome it; in stupor the arrest of psychic activity is so complete that the patient makes no attempt to react.

(2) The patient's mind is preoccupied by intense, frightful delusions. There is an endless succession of terrifying hallucinations analogous to those of epileptic delirium. The patient is in a frightful nightmare which completely absorbs him, rendering him insensible to impressions of the external world.

Course, Duration, and Prognosis of the Depressed Type of Manic-Depressive Psychoses. - As in mania, the course is irregular, interrupted by temporary remissions and exacerbations. The duration varies within very wide limits, from a few days to several months or even years; the prognosis is always favorable for recovery from the attack, except in cases with grave somatic complications.

Physical improvement, especially increase in weight, usually indicates the approach of recovery. The treatment consists in:

(1) Sustaining the strength of the patient by rest, especially rest in bed, and by a plentiful and nutritious diet;

(2) Careful watching to prevent suicide;

(3) Calming agitation, when present, by the usual procedures;

(4) Combating the gastric disorders and the phenomena of autointoxication that are so frequent in states of depression.

Psychic treatment in the form of suggestion, moderate physical and intellectual labor, etc., is of great service during convalescence, but is contraindicated during the acute period of the disease.