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 insanity; 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.

Disturbance of the 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 that the patient is entering upon his 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 lamentations and heart-rending cries. 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, Delusional melancholia. - All varieties of melan

choly delusions are encountered in this affection: ideas of culpability, of humility, of ruin, hypochondriacal ideas, and ideas of negation. The syndrome of Cotard scarcely ever appears. It is not uncommon for persecutory ideas to occur in combination with melancholy ideas proper.

Hallucinations are not frequent. The least rare are, according to Séglas, those of vision and of the muscular sense. Those of hearing, taste, and smell are occasionally met with, while those of general sensibility are altogether exceptional.

Illusions of all sorts are, on the contrary, frequent. They often assume the form of mistakes of identity.

Finally, delusional interpretations are constant. The patient hears the noise of hammer-strokes in the vicinity and thinks a scaffold is being built for him. He hears the sound of voices in the street and thinks the mob is going to seize and lynch him, etc.

The reactions are usually in harmony with the melancholy state and with the nature of the de lusions. Sometimes, under the influence of anxiety which in many cases accompanies the delusions, the reactions assume an exclusively automatic character; it is to be noted that negativism is not uncommon.

The following case illustrates both delusional melancholia and anxious melancholia.

a

Margaret L., fifty-eight years old. — Paternal and maternal heredity: father was alcoholic, died of disease of the liver; mother eccentric, unduly irritable; one maternal aunt committed suicide. The patient has always been nervous and sensitive. She has been, however, of normal intelligence and always attended properly to the work of her home and family. She has two daughters, respectively thirty and twenty-five years old, both normal. Menstruation ceased two years ago.

The mental symptoms began with a state of general depression and discouragement. On being invited to a christening of a little boy she refused to go, giving as her reason that life is a burden and that there is no cause for rejoicing in the birth of a child. After several weeks she began to show very marked uneasiness and a little later delusional interpretations. She saw wagons passing by the house loaded with various objects, furniture, bedding, barrels, sacks of flour; she heard the drivers cracking their whips; all this alarmed her greatly and she asked her husband whether all this did not signify that she was to be thrown out of the house and left to starve to death. She noticed also that the neighbors looked at her queerly whenever she met them. At the same time physical symptoms appeared: complete loss of appetite, headaches, insomnia. About two weeks later, namely, March 20, 1900, she developed an idea of self-accusation. About twenty-five years ago she lost a little daughter from croup. Did not this child die because its mother had left it one day with its feet wet? This idea at first had the character of an imperative idea; the patient knew it was false and tried to drive it away; it, however, grew more and more dominating and was finally accepted by the patient as true: the imperative idea became a fixed idea. The psychio pain increased steadily. New delusions sprang up, the first one, however, still remaining active. On April 12 the patient went to the police headquarters carrying a bundle of clothing; this, she said, was for those poor girls who are robbed of everything and thrown out into the street. At the same time she begged the police authorities to send men to protect those unfortunate women whom the Prussians were about to ravish.

On being taken to a sanitarium she did not cease to wail and to lament, first accusing herself, as formerly, of the death of her little girl, later of the illness of her husband, who really did have heart trouble. Gradually the delusions grew. She claimed she had brought upon her relatives such disgrace and misery that they all committed suicide; the letters which she is supposed to receive from them are false; no doubt this is done to console her; everybody has been too good to her; a nasty creature like her should have her head chopped off. There she is, well fed and housed, and warmly dressed, yet they know well that she has no money to pay for all this.

But this cannot last; pretty soon the day will come when they will put her out to go and beg. She developed a few hallucinations of sight, of hearing, and of muscular sensibility: several times she saw before her a pool of blood; also several times she heard the voices of her children crying: “Bread! Give us bread!” Finally she complained of feeling an inner voice coming from her breast, which made her say against her own will: “Slut! slut!” She cries loudly, begging to be put to death; has made repeated attempts to commit suicide; from April 21 to October 30, five such attempts were counted, three of which were by hanging. For a time she refused food; after being tube-fed for two days, she began to eat again, although with much difficulty.

Considerable emaciation. Tongue coated. Breath very foul. Constipation. Slight trace of albumen in the urine.

Such is the fundamental and habitual state of the patient. The anxiety, without being ever entirely wanting, presents, however, periods of exacerbation, so that the patient at times shows the typical picture of anxious melancholia. During such paroxysms the patient seems to be literally suffocating. She seems to be striving to throw off a weight from her chest; she pulls her hair, strikes herself in the face, and scratches at the walls of her room until her fingers bleed. When her agitation is at its height it is impossible to obtain from her a response to any question. She