In epidemic influenza among the insane the gastric symptoms are often very severe, and it is likely that the pneumogastric nerve becomes involved in the general inflammatory processes of this

disease.

The abdominal branches of the vagus influence the glycogenic function of the liver and intestinal digestion, but knowledge is not yet sufficiently definite in this direction to admit of its application in mental diseases., After section of the intestinal branches of the vagus purgatives fail to act, and it is likely that this physiological fact may afford some explanation of the obstinate constipation among the insane who manifest other symptoms of pneumogastric disorder.

There is also a dearth of positive knowledge as regards the action of the pneumogastric on the kidneys, though irritation of this nerve is known to produce diabetes. The frequency of kidney diseases in the insane may some day be in part explained through pneumogastric irritation.

Much future research will be necessary in order to clearly show the full history of vagus diseases in insanity, but sufficient positive points have already been given, it is hoped, to excite an interest in this subject, and to fully justify the belief, that there is frequent disorder of pneumogastric function in insanity. The existence of these pneumogastric affections in mental diseases is in accordance with our knowledge of experimental physiology and of pathological law and is confirmed by clinical observation of insane patients, and is proved by autopsical examinations in the insane, showing both macroscopical and microscopical lesions of the pneumogastric nerve and of its central nuclei.

THE UNITY OF MANIA AND MELANCHOLIA.

BY E. A. CHRISTIAN, M. D.,

Assistant Medical Superintendent Eastern Michigan Asylum, Pontiac.

There is much in the various systems for classifying cases of insanity that is unsatisfactory and disappointing; and to none does the realization of this come more vividly than to those who are the most frequently called upon to engage in the work. In grouping cases of mental disease under the various forms in some one of the many tables in use to-day, the tabulator finds himself hesitating, now and then, in his decision, or meeting with a name, here and there, already figuring in tables of past years which now reveals itself to him in different light. These occurrences are frequent enough to give rise to the desire for some more comprehensive system than any we now possess. The difficulties met with, however, are such as are inherent in any system founded upon groups of symptoms rather than upon pathological changes productive of those symptoms. In the absence of data for a pathological grouping we must classify symptomatically, with results quite as satisfactory, perhaps, in the treatment of the disorder.

One might naturally suppose that in mania and melancholia, at least, we have forms of mental disease so distinct in their manifestations that doubt and hesitation would be eliminated in classifying cases falling in one or the other of these forms. To many these terms stand as distinctive appellations for pathological entities diseases of the mind. So we find them in text books, and in use in clinical teaching, and so they will continue to be used, because of their convenience.

I desire to call attention to some points of resemblance between these two manifestations of mental disorder. Are they distinct forms of disease? Can we discover any common pathological basis for them? I do not refer in this latter query to those many different structural and functional disorders of the various organs of the body, which may indirectly bring about one of these forms of mental perturbation: but to state the question again, what is there in the domain of mental pathology which lies at the bottom of mania and its apparent opposite, melancholia?

The thought that comes into my mind, and which I desire to make plain if I can, is, that these apparently opposed states are not so alien to each other as they seem; that they have something in common—a something which may perhaps at some time form a basis for a better system of classification than we now have.

To make myself clearer I present two propositions-first, that mania and melancholia are not diseases but mental states, and, second, that the psychical basis of both mania and melancholia is to be found in alterations in the personality. Now, the individual's personality is not such an intangible, metaphysical conception as may at first appear. It is a something which has material existence, in the nervous elements of the body, and which is demonstrable to the reason. Its seat is in the ganglia of the sympathetic and of the cerebro-spinal nervous systems, and in their centrifugal and centripetal filaments. It manifests itself in the operations of these organs with the cortical brain cells which register and reproduce impressions.

This is not so abstruse as it may seem. Every organ of the body is constantly sending to the brain nervous impulses, only a small portion of which become part of the individual's conscious life. In health he takes little or no cognizance of most of them; but let these impulses proceed from viscera whose natural operations are deranged, and there comes at once into his consciousness a vague discomfort; a malaise so difficult to define or locate. It is the sum total of these incessant centripetal impulses, the "common sensation" the coenesthesis, as it has been called, registered in the organic memory which furnishes the physical basis of the personality. This common sensation is ebbing and flowing from day to day; a fluctuation within certain limits is normal to every individual, upon it depends his half conscious sense of well-being in health, as well as the vague discomfort experienced at other times, -in other words his "spirits"; at its flood we have a buoyancy of spirits, an enjoyment of living and a corresponding stimulation of activities in all lines. The perceptions are quickened and mental operations are carried on with a minimum sense of effort. Overflowing its normal confines, there result the busy restlessness and the loquaciousness of a mild maniacal disturbance. Carried still further there ensue the too rapid registration of sense percepts, the running of them together into a jumble of incoherent concepts, which are expressed in language equally incoherent. At its ebb

come the depression of spirits, the malaise, the introspection, the magnifying of all subjective impressions which constitute the essence of a mild melancholia; and later the appearance in the mental life of erroneous judgments or delusions—incorrect inferences drawn from perverted sensations.

Mania and melancholia have their origin, then, in opposed mental states, both of which depend upon either an exaltation or a depression of constant vital activities, and which manifest themselves chiefly in an increase of the object or subject-consciousness. Accepting this common origin of these troubles, it becomes easier at once to understand some of the difficulties encountered in the classification of certain cases of mental disease. It is generally supposed, so far as the purely intellectual processes are concerned, that we have in mania a quickening of the object-consciousness, percepts from without coming into consciousness chiefly and mental operations reflecting themselves outwardly; that in melancholia there is an exaggeration of the subject-consciousness, subjective percepts crowding out the objective and the attention becoming fixed upon the individual himself. In the affective or emotional region we are supposed to find pleasurable feelings in mania with a corresponding painful state of the emotions in melancholia. This would seem to furnish a sufficiently easy basis for classifying such cases. But in practice we find cases, and they are by no means infrequent, where with the most terribly painful state of the emotions object-consciousness predominates. Many such cases are easily placed in the category of melancholia with frenzy. But where shall we place those cases where these antipodal characteristics are displayed as different scenes in the progress of the disease? I do not refer now to distinctly alternating attacks of excitement and depression where the mental experiences in one state seem to bear no relation to those of the ensuing state, but to such a case as the following one where there is no break in the mental experiences but a gradual transformation in the conduct of the individual.

A young man after close application to work and to other pursuits breaks down suddenly while attending church services. He confides to the clergyman ambitious plans. He sends telegrams and writes letters in profusion. He challenges Robert Ingersoll to a joint debate. He talks in an extravagant strain about the Panama canal and converses on intimate terms with both God and the

devil. On admission to the asylum he recognizes promptly certain former acquaintances, but applies wrong names to them. He removes his clothing and when reproved by his attendant he impulsively strikes him. Ten days later he displays noisy excitement, imagining himself a noted pugilist and making frequent assaults. At the same time he is mischievous, untidy and exasperatingly annoying to other patients, wearing constantly a smile of self-satisfaction. At the beginning of the second month we find a reversal of the picture. The change though complete was not altogether abrupt. The patient's hands and feet are cold and swollen. He refuses to talk. His head is lowered upon his chest and he permits saliva to flow from his mouth. At times he throws himself to the floor in the attitude of crucifixion and seeks to denude himself. Occasionally he strikes himself by way of penance. The religious delusions which at this time prompted him to acts of self-punishment were but a transformation in those which existed at the time of his reception and which gave then a picture of religious exaltation. On his admission he was counted a case of mania. One month later he was a typical picture of profound melancholia. Had the patient subsequently alternated between these two conditions, his case could properly have been denominated one of circular insanity, but in the five years which have since elapsed the circular feature has been wanting.

With the disappearance of the acute stage he passed into a state of moderate dementia with fixed delusions not easy to classify-a terminal dementia not characteristic in its features of any previous acute stage.

There are several forms of relapsing insanity which spring indifferently from primary attacks of mania or melancholia. In the typical circular insanity we have alternating periods of profound melancholia and active elation, with or without an intervening quiescent stage. In neither of these extremes does the symptom picture presented differ from mania or melancholia simple. The individual, however, passes through a cycle in which his personality undergoes radical changes, and when once this cycle becomes established the victim passes the remainder of his life floating helplessly backwards and forwards between happiness and despair. In many cases the intellectual forces are disturbed only in so far as they may be quickened or weighted down by the state of the emotional centers; delusions making no appear