certainly infinitely more rare than was believed by older authors, constitutes none the less a reality. Cases exist presenting all the symptoms characteristic of the manic state- flight of ideas, excitement morbid irritability, pressure of activity, etc.— and in which these symptoms, instead of being intermittent, become established in definitely chronic fashion.

Chronic forms are seen chiefly in elderly subjects, for the most part after the age of sixty years. They are often associated with a certain degree of intellectual enfeeblement of which it is impossible to say whether it is directly dependent upon the manic state or whether it constitutes a deterioration of senile origin superimposed somehow upon the manic state. When we consider that in classical manic depressive insanity even severe and repeated attacks leave no marked intellectual enfeeblement the second assumption appears more logical.

It is exceptional for a chronic manic state to be installed as such from the beginning. More often it follows one or several attacks of ordinary manic depressive insanity ending in recovery. The patient has one, two, three attacks from which he recovers completely; then comes on another attack in every way resembling the previous ones; the excitement subsides somewhat, periods of relative calm occur at intervals; recovery seems to be approaching, but the condition continues indefinitely and it finally becomes apparent that the acute maniac has become a chronic maniac. At times the chronic state is marked by extreme weakness of attention; this

was observed in the following case, the history of which I shall review briefly, and which may serve as a general type from several points of view,

Mrs. C. J., two of whose cousins are insane, was born in 1844. In 1869, that is to say, at the age of twenty-five years, following a confinement, she had an attack consisting of a period of depression and one of excitement, the whole attack lasting eighteen months. She recovered and remained well until 1891, when, without apparent cause, she had another similar attack from which she recovered at the end of two years, following a surgical operation upon the uterus. In 1901 a third attack: period of depression lasting several months, later, following a trip on which she was taken for diversion, sudden appearance of the manic state. Another surgical operation upon the uterus was tried, but without any result. Since 1901 excitement, flight of ideas, and logorrhoea have persisted with intervals of lucidity which gradually become rarer and shorter. These intervals, which at first lasted several days, have not lasted longer than one or two hours during the first half of 1908. At the present time (September, 1908) they hardly exceed half an hour and, as I have already mentioned, they are notably more rare than during the first year of the disease. Moreover, even in the moments of lucidity which still occur from time to time a certain degree of intellectual enfeeblement is observed. Affectivity is reduced, recollections are lacking in precision, attention is fixed with some difficulty, and orientation of time is defective. There seems to be no doubt that we are here dealing with a state of chronic mania with slight intellectual enfeeblement. The most pronounced disorder, the one which especially characterizes the case in question and distinguishes it from attacks of manic depressive insanity such as one is accustomed to seeing, is an extreme weakness of attention, a weakness which is out of all proportion to the motor excitement and which makes it impossible to obtain a sensible reply even to the simplest questions, while at the same time it is easy to obtain relative psychomotor calm, sufficient, for instance, to keep the patient seated in a chair.

CHAPTER VI.

INVOLUTIONAL MELANCHOLIA.

THE causes of this disease are not well known. Neuropathic heredity has been found in about 60% of the cases. The most frequently mentioned factors are grief and stress. Occurring chiefly after fortyfive years of age, it seems to be intimately 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

1 Capgras. Essai de réduction del a mélancolie à une psychose d'involution présénile. Thèse de Paris, 1900. Kraepelin. Lehrbuch der Psychiatrie.

patient appears as though dumbfounded by the pain. “A frightful internal anxiety constitutes the fundamental state, which torments him almost to suffocation."1

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.

In cases of slight or moderate intensity the 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 insanity. We have seen, in fact, that the intensity of psychic inhibition is inversely proportional to that of psychic pain; naturally, therefore, 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 insanity. These two affections seem to be closely related to each other, and borderland cases are not uncommon.

The recent study of Dreyfus indicates clearly that the relationship between involutional melancholia and manic depressive insanity, here pointed out, is, indeed, a very close one. This study con

1 Griesinger. Loc. cit., p. 292.

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

sists 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 variety of mixed form of manic depressive insanity; and Kraepelin in a preface contributed by him 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 insanity."

Thus it would seem that the autonomy of involutional melancholia as an independent 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 insanity, it nevertheless presents special and characteristic features, among which may be mentioned its frequent development following