in passive melancholia; but it is not an acute and distinct psychical pain. It is but vaguely perceived.” 1

Passive depression.—The fundamental features of passive depression are lassitude, discouragement, resignation. It is always associated with a marked degree of psychic inhibition, aboulia, and moral anesthesia, and may be complicated by delusions and hallucinations. It is accompanied by organic changes which have been extensively studied by physiologists (Darwin, Claude Bernard, Lange), and to which Dumas has devoted one of the most interesting chapters in his book, "La tristesse et la joie."

Depression is always associated with a state of peripheral and probably cerebral vaso-constriction, in which Lange believed he had found the immediate cause of this emotion. This vaso-constriction is apparent in the pallor of the skin, coldness of the extremities, and absence of the peripheral pulse, which are constant features of the depression of melancholia. The opinion of Lange is, however, too exclusive. "This vaso-constriction, which in the peripheral organs results in coldness and pallor of the tissues, brings about in the brain a condition of anæmia, undoubtedly contributing to the maintenance of the mental and motor inertia; but it cannot be asserted positively that it is the only cause of these phenomena. Morselli and BordoniUffreduzzi have shown long since, in fact, that the phenomena of depressed intellectual activity may appear before the cerebral circulatory changes; this leads to the conclusion that depression begins with being the

1 La tristesse et la joie, p. 29. Paris, F. Alcan.

cause of the circulatory changes before becoming subject to their influence." 1

In the very rare cases in which, in spite of the peripheral vaso-constriction, the cardiac impulse retains its force, the blood pressure, according to the laws formulated by Marey, rises; this condition constitutes the first type of depression, depression with hypertension.

But almost always the heart participates in the general atony to which the depression gives rise, so that the blood pressure falls in spite of the peripheral vasoconstriction: this constitutes the second type of depression, depression with hypotension (Dumas).

The respiratory disorders are no less constant than the circulatory ones. The respirations are shallow, irregular, interrupted by deep sighing. The quantity of carbon dioxide excreted tends to diminish.

The general nutrition is impaired; this results in loss of flesh, which is but slight if the depression lasts no longer than a few days, and which persists as long as the affective phenomenon itself. The weight does not return to the normal until the depression disappears, i.e., until the patient either recovers or becomes demented.

The appetite is diminished, the tongue is coated, the breath is offensive. The process of digestion is accompanied by discomfort and often by pain in the epigastrium. Finally, there is almost always constipation.

The sluggish metabolism shown by the diminished elimination of carbon dioxide is also apparent from the quantitative and qualitative changes in the urinary

1 Dumas. Loc. cit., p. 239.

excretion. The quantity of urine voided in twentyfour hours is diminished. The quantity of urea, as well as that of phosphoric acid, is also diminished (Observations of Dumas and Serveaux).

The toxicity of the urine in depression is undoubtedly of interest, but the results so far obtained are somewhat conflicting. According to some authors it is increased, according to others, diminished. This subject, still in a state of confusion, should be excluded from the domain of practical psychiatry.

Active depression. -The special feature of active depression is the psychical pain, which is distinct and sufficiently intense to render the subject subjectively conscious of it. The appearance of this new phenomenon modifies to a certain extent the fundamental symptoms which have been described in connection with passive depression.

Like physical pain, psychical pain tends to limit the field of consciousness, to exclude other intellectual manifestations, and to become what Schüle has designated by the term pain-idea. In certain cases the disturbance of consciousness which it causes results in marked disorientation and confusion. These phenomena, caused by the pain, become less marked as the pain becomes abated in intensity and disappear as the paroxysm passes off.

When psychical pain attains a certain intensity it results in anxiety. This phenomenon consists chiefly in a feeling of oppression or constriction, most frequently localized in the precordial region, occasionally in the epigastrium or in the throat, and more rarely in the head. This peculiar feeling is always accompanied by

certain somatic phenomena, the most important of which are pallor of the skin, sometimes actual cyanosis, panting respiration, general tremor, irregular and accelerated pulse, and dilatation of the pupils, which is often very marked.

Anxiety is frequently seen in the melancholias. It also occurs in cases of obsession. It may appear without cause in certain psychopaths (the paroxysmal anxiety of Brissaud).

From the standpoint of the reactions, psychical pain, like physical pain, may manifest itself either by a sort of psychomotor paralysis, - so that the patient remains immovable, with a haggard expression, silenced, so to speak, by the anxiety, - or by various phenomena of agitation.

In the latter case, the more frequent, the pain, an active phenomenon, brings about a reaction which to a certain extent overcomes the fundamental psychic inhibition and manifests itself by two symptoms which are frequently seen together, motor agitation and delusions.

Acting as a stimulus, psychical pain overcomes the motor inertia of melancholia and gives rise to melancholic agitation, which is characterized by movements that are, in the normal state, the expression of violent despair. The patient wrings his hands, strikes his head against the wall, etc. The agitation of anxiety is essentially an expression of opposition, of resistance. The reactions are either automatic or governed by delusions: movements of flight, refusal of food, attempts of suicide, etc.

Suicide is one of the most formidable consequences of

psychical pain. Though most melancholiacs have a desire to die, the aboulia which characterizes the state of depression very seldom permits them to carry out their desire. On recovering part of their energy they are apt to make suicidal attempts.

Delusions are a frequent but not a constant manifestation of psychical pain. They are absent in certain cases of melancholia in spite of the existence of even very painful depression.

What is the mechanism of the production of delusions in melancholia? The most widely accepted opinion is that of Griesinger: "The patient feels that he is a prey to sadness; but he is usually not sad except under the influence of depressing causes; moreover, according to the general law of cause and effect, this sadness must have a ground, a cause, — and before he asks himself this question, he already has an answer; all kinds of mournful thoughts occur to him as explanations; dark presentiments, apprehensions, over which he broods and ponders until some of these ideas become so dominating and so persistent as to fix themselves in his mind, at least for some time. For this reason these delusions have the character of attempts on the part of the patient to explain to himself his own state.”

Though of great interest, this ingenious theory is perhaps somewhat too exclusive. Kraepelin remarked, in fact, that the delusions occurring in states of depression do not always present the character of explanations sought by the patient. Many melancholiacs instead of accepting the delusions, on the contrary

1 Griesinger. Pathologie und Therapie der psychischen Krankheiten.