The essential cause of this disease seems to be bad heredity. Among other factors those most frequently mentioned are grief and stress. Occurring chiefly after forty-five years of age, it seems to be in some way connected with the phenomena of organic retrogression beginning at this age; hence the name "involutional melancholia."

The prodromal period, which is almost constant and usually very long, indicates a profound, slow, and progressive change of the entire organism: the process of digestion is painful; there are anorexia, insomnia, irritability, unwarranted pessimism, and a tendency to rapid fatigue.

Finally the disease sets in, characterized from the beginning by intense psychic pain.

It presents itself with the train of physical and psychic symptoms already studied in connection with active depression. When associated with anxiety it gives rise to anxious melancholia.1

The anxiety may result either in agitation (melancholia agitata) or in stupor. In the latter case the patient appears as though dumbfounded by the pain. "A frightful internal anxiety constitutes the fundamental state, which torments him almost to suffocation." 2

When the psychic pain is very marked, it entails sometimes a certain degree of mental confusion which is most frequently transitory and subject to the same fluctuations as the pain itself of which it is a manifestation.

1 Capgras. Essai de reduction de la melancolie a une psychose d'involution presenile. These de Paris, 1900. - Kraepelin. Lehrbuch der Psychiatrie.

2 Griesinger. Loc. cit., p. 292.

In cases of slight or moderate intensity lucidity is perfect and sometimes permits the patient to analyze his case with considerable minuteness.

Association of ideas is sluggish, less so, however, than in the depressed form of manic-depressive psychoses. We have seen, in fact, that the intensity of psychic inhibition is inversely proportional to that of psychic pain; accordingly the inhibition occupies here a secondary position. Between the cases in which the sadness clearly predominates and those in which the inhibition is the principal feature, there is a host of intermediary forms which establish an insensible transition between involutional melancholia and manic-depressive psychoses. These two affections seem to be closely related, and borderland cases are not uncommon.

The recent study of Dreyfus! indicates clearly that the relationship between involutional melancholia and manic-depressive psychoses is, indeed, a close one. This study consists in a careful investigation of the entire subsequent course of all cases admitted to the Heidelberg clinic since 1892 and classified as involutional melancholia. The facts revealed by the investigation are: the great majority of the cases which had not terminated in death through some complication resulted in complete recovery; in a small percentage of the cases deterioration ultimately occurred apparently on a basis of cerebral arteriosclerosis which such cases seem to be particularly prone to develop; more than half of the cases had more than one attack; in many cases manic symptoms were observed: fleeting euphoria, irritability, loquaciousness, flight of ideas, etc. These results led Dreyfus to the conclusion that involutional melancholia was but a special mixed form of manic-depressive psychoses and Kraepelin, in a preface contributed to the work of Dreyfus, evidently accepts this conclusion in the following words: "These results show, at least for the main bulk of the cases which we have designated as involutional melancholia, that there is no longer any basis compelling their separation from manic-depressive psychoses."

1 Die Melancholie ein Zustandsbild des manisch-depressiven Irreseins. Jena, 1907.

Thus it would seem that the autonomy of involutional melancholia as a separate clinical entity is destroyed. We have, however, allowed the description of it in this Manual to remain, partly for the reason that it still figures in hospital statistics, but mainly for the reason that, admitting its kinship to manic-depressive psychoses, it nevertheless presents special and characteristic features, among which may be mentioned its frequent development following actual depressing causes (death of a near relative, financial ruin); its grave form characterized by long duration (in many cases over five years, in some over ten years), frequent fatal termination; combinations of symptoms not commonly observed in typical attacks of manic-depressive psychoses; the occurrence in nearly half of the cases of only one attack during the life of the individual.

The sadness may in itself become a cause of psychic inhibition and create melancholia with stupor.

To these psychic phenomena are added physical disorders most of which have already been considered:

Respiratory and circulatory disturbances which are dependent upon the depression and anxiety.

Disturbances of digestive functions; anorexia, dyspepsia, painful digestion, constipation.

Impairment of the general nutrition, changes in the composition of the urine (diminution of urea, slight albuminuria), and rapid loss of flesh. The latter symptom is of particular importance; a rise in weight usually indicates beginning convalescence.

The menses are usually suppressed. Their reappearance has the same prognostic significance as the return of the normal weight; it indicates the approach of recovery.

Finally, there are various nervous troubles: headache, palpitation, tremors, hysteriform crises, and insomnia.

These are the fundamental symptoms of involutional melancholia in its simplest form and uncomplicated by delusions. This form is rare; generally the disease assumes one of the following two forms, or some combination of the two: anxious melancholia and delusional melancholia.

Anxious Melancholia

The psychic pain, which is here very intense, manifests itself by the mental and physical symptoms of anxiety, which have already been described in the first part of this book: more or less complete cessation of mental processes, in some cases a certain degree of mental confusion at the time of the paroxysms of anxiety; an extremely distressing sense of constriction generally localized in the precordial region or in the throat, less often in the head; pallor and pinched expression of the face, coldness and cyanosis of the extremities, irregular and shallow respirations; lowering of blood pressure; small, compressible pulse, either rapid or slow; dilatation of the pupils.

From the point of view of the reactions anxious melancholia is characterized either by agitation or by stupor.

The agitation of melancholia presents the appearance of despair: the patient wrings his hands, strikes his head against the walls, and gives vent to cries and lamentations. It is monotonous and often marked by very pronounced negativism. The phenomena of agitation are sometimes purely impulsive in origin and occur in the shape of sudden attacks which may be very brief. During such attacks the patients may display a tendency to violent acts of danger to themselves or to others (suicidal or homicidal attempts). Such paroxysms constitute the so-called raptus melancholicus.

Psychic pain may, like physical pain, paralyze more or less completely all mental functions. Thus is explained the manner in which anxious melancholia may become transformed into stuporous melancholia; these two forms, seemingly so different, are in reality closely related. The psychic inhibition which characterizes stuporous melancholia is essentially a secondary phenomenon.

Anxious melancholia sometimes exists in a state of purity, either as agitated melancholia or as stuporous melancholia. Much more often it is complicated by delusions.