The Depressive Phase of Manic-Depressive Insanity

IT iS to the genius of Kraepelin, whose death in 1926 must have spared him the pain of encountering Nazism, that we owe both the title and our present conception of manic-depressive insanity. This conception embraces far more than the clinical close relationship which sometimes exists between states of mania and states of melancholia. A good deal, in fact, was known about this relationship before Kraepelin's time, and its importance has, I believe, been considerably overstressed. A small percentage of patients undoubtedly exhibit in their lifetime attacks of both mania and melancholia. A still smaller percentage exhibit alternating cycles of the two conditions with few or no remissions. A mild elation is not infrequently observed at the termination of a melancholic attack, and transitory periods of depression may occasionally be observed during the course of an attack of mania. When all this is said, however, the fact remains that in the great bulk of cases no such relationship is evident, and the diseases progress with utterly dissimilar symptoms along entirely different courses. On symptomatology alone, therefore, there would, I fear, be little justification for the conception embodied in the term "manic-depressive." Kraepelin, however, probed more deeply into the problem, and his great contribution, and, in my opinion, justification for his conception, lay in his elucidation of what he termed the "fundamental states" common to both conditions. Although we can today , in the light of much fine work done on the psychology of the child, considerably amplify Kraepelin's viewpoint of the abnormalities of temperament which he terms "fundamental states," yet his descriptionl of these four states which he calls the "depressive temperament ," the "manic temperament," the "irritable temperament," and the "cyclo-thvmic temperament," must remain a classic in the literature of psychological medicine. In the paper which follows I propose to limit myself to a consideration of the purely clinical aspects of the depressive phase of manic-depressive insanity, or, as it is more commonly known, melancholia. MELANCHOLIA. Melancholia holds an almost unique position amongst diseases in that it is characterized by only one essential symptom-mental or emotional depression. The fact, however, that there is onlv one symptom essential to diagnosis often makes the latter a very difficult problem. Two crucial questions present themselves ; firstly, whether depression is or is not present, and, secondly, whether such depression is of such a character as to justify a diagnosis of melancholia. An …