CHAPTER XIIINVOLUTION MELANCHOLIA
In 1896 Kraepelin first definitely outlined his views on dementia praecox, to which he assigned hebephrenia, although he did not at the time include katatonia in his delimitation of that disease. He also described melancholia in his fifth edition, classifying it as an involutional or retrograde presenile process (Das Irresein des Rückbildungsalters). He had not as yet formulated his theory of the manic-depressive psychoses although he described manic and depressive forms of periodical constitutional disorders. In 1899 he discarded the mania and melancholia of other writers altogether or rather included them in his new manic-depressive group, but still retained melancholia as a distinct entity occurring in the involutional period of life only. As has already been shown, melancholia is a term which had been used for centuries and in a general way applied to depressions of any and all types. Kraepelin's manic-depressive psychoses and dementia praecox very largely destroyed the integrity of this old-time conception. It has been shown, furthermore, that depressive states often constitute an integral part of the picture of general paresis. Symptomatic depressions more or less distinct in character have been associated with a number of somatic diseases. Senile psychoses, epilepsy, various organic conditions, the psychoneuroses and the psychopathic personalities have depressive manifestations well recognized and readily classifiable.
Kraepelin, however, pointed out the fact that therewas another group still unaccounted for—the anxious depressions of later life, which he included under the designation of involution melancholia and which did not belong to the manic-depressive group. This he described as being preeminently a depression associated almost always with anxiety and fear as prominent symptoms. Accompanying this condition there are usually ideas of poverty, sin, or impending danger of some kind. Delusions of self-accusation are quite common. Anxious restlessness or agitated excitement is to be expected in a majority of the cases. There is usually no clouding of the consciousness, although, as Hoch expresses it, "the mental horizon may be more or less narrowed to the depressive ideas." The memory as a rule is not impaired. Hallucinations of sight and hearing are often present. Somatic delusions of a hypochondriacal nature occur. Insomnia is usually marked. The tendency of the disease is towards deterioration. Retardation and psychomotor inactivity are not to be expected. Melancholia is to be differentiated from manic-depressive insanity by the prominence of anxiety and apprehension, the absence of any retardation or psychomotor inhibition, the unusual frequency of self-accusation with ideas of sinfulness, the clearness of the sensorium, the comparatively unfavorable prognosis and the great frequency of suicidal impulses. The age, and the absence of previous attacks, is, of course, exceedingly important in arriving at a diagnosis. The onset of the disease is usually between the ages of forty and sixty, but not infrequently it begins with the menopause in women, and Kraepelin states that sixty per cent of the cases occur in the female sex. He found a history of defective heredity very common. The precipitating factor is often some mental shock, the illness or death of friends, or disasters of various kinds. No distinctive pathology of the disease has been described by Kraepelin. He was uncertain as to the rôle playedby arteriosclerosis in its etiology. Diefendorf[283]reported that about one-third of the cases made complete recoveries; twenty-three per cent were able to return to their previous surroundings; twenty-six per cent terminated in an advanced state of deterioration and nineteen per cent died within a period of two or three years.
In 1907 Dreyfus,[284]at that time an assistant of Kraepelin's, made an elaborate study of the cases previously diagnosed as involution melancholia in the Heidelberg clinic. During a period of fourteen years, a total of seventy-nine were reported. A thorough investigation by Dreyfus showed that two-thirds of these had made complete recoveries or improved to such an extent as to be able to go home. Only eight per cent showed a marked mental deterioration. He also found that over half of the series had more than one attack, usually depressions. One-third of the patients died and were thus eliminated from further consideration. The duration of the attack was over three years in one-third of the cases reviewed. Fifteen per cent recovered in from three to five years, nine per cent in from six to eight years, and eight per cent in from ten to fourteen years. He was of the opinion that after a careful study of the hospital records the symptoms found could all be explained on the basis of manic-depressive insanity, usually of a mixed form. Kraepelin had reported that forty-nine per cent of his cases deteriorated mentally. Dreyfus reduced this on further observation to only eight per cent. On analysis he found, in many instances, brief periods of manic elation, sometimes only a matter of hours or a few days, evidences of excitability, manic suggestion in the eagerness of the patient to communicate his troubles to others, and inhibitory processes indicated by a lack of interest,loss of affection or even difficulty of thinking. Dreyfus concluded that the depressions of late years were not so common as had been supposed and that a sufficient knowledge of their history showed that they had usually exhibited previous attacks. He thought that the long duration of the disease probably led to erroneous ideas as to its termination in deterioration.
Kirby[285]is of the opinion that Dreyfus based some of his findings on insufficient evidence, as shown by his published case records:—"In a considerable number of other cases the author's conclusion that manic-depressive symptoms were present is based on extremely meagre data. As an illustration one case may be referred to briefly. A man fifty-three years old had an agitated depression lasting over two and one-half years and terminating in recovery. The case record contains no statement of any objective inhibition or feeling of subjective insufficiency, neither are there any statements regarding flight of ideas, or unusual loquacity. The diagnosis, however, is made of manic-depressive insanity, with partial psychomotor inhibition and flight of ideas. The assumption that these symptoms existed is based entirely on the retrospective account from the patient, obtained three years after recovery from the psychosis. He then declared that during the attack he could not think calmly; it seemed that one thought "knocked the other down," one thought "hunted after the other." He also described a feeling as if there were a cap on his head, as if he were nailed down. These retrospective statements are interpreted to mean that there was partial psychomotor inhibition and flight of ideas. In many other cases the reasoning is just as forced and the deductions based on equally insufficient grounds.... The author's aim wasto see if the symptoms present fitted into certain schematic formula and thus the analysis became rather a search for diagnostic signs supposed to characterize a definite form of disease. Such a method leads away from consideration of the mental disorder as a whole; a few minor features are emphasized in the picture and because the patient recovers these are raised to diagnostic importance—a little feeling of insufficiency or a slight change of mood in a disorder which ends in recovery are seized upon as evidence that a special kind of disease exists; as a matter of fact, we would hardly miss just such symptoms in many other psychoses. There is no attempt to get below the surface, to understand the evolution of the disorder, or to use the facts in the development in formulating the prognosis."
In the introduction to the book written by Dreyfus in 1907, Kraepelin nevertheless expressed the opinion that "These results show that for the most of these disorders which have been designated as melancholia there now exists no sufficient reason to separate them from manic-depressive insanity." This at the time was looked upon as definitely settling the fate of the melancholia concept and it was abandoned by some. As a general rule, however, the psychiatrists of this country seem to have accepted Kraepelin's original description of the disease as being thoroughly justified. To use White's words, "Many psychiatrists still believe, although Kraepelin himself accepts Dreyfus' conclusions, that there is still a place for involution melancholia distinct from the manic-depressive group."
In his eighth edition Kraepelin[286]discusses melancholia as a presenile condition and reviews the whole situation in considerable detail. He shows that symptomatic considerations alone did not guide him in his original conception of the disease. A great deal of weightwas attached to prognosis and certain forms were separated out and differentiated from manic-depressive because they tended towards mental enfeeblement. He calls attention to the fact that Thalbitzer disputed the integrity of melancholia in 1905, classifying it as a manic-depressive reaction. After reviewing the findings of Dreyfus he admits that the conclusions of the latter are in the main correct and that involution melancholia as originally described cannot be retained as a definite entity. "The significant fact still remains," he says, "that single attacks of depression are disproportionately common in the involution period." Hübner, for instance, found twenty-one single attacks of melancholia after the fiftieth year of age to only two single attacks of mania. "The appearance of depressions, therefore, through the revolutions of this period of life seems to be favored to a special degree." He again states that he is unable to determine what rôle is played in the involutional depressions by beginning arteriosclerosis or the onset of senile conditions. He concludes, however, that a form of depression, earlier described as melancholia, is still to be separated from the manic-depressive psychoses although not entirely clear as to its significance or exact delimitation.[287]
These are the most severe and rapidly fatal forms of anxious excitements, as a rule developing suddenly and included now in his presenile group. "These cases are anxious, restless, sleepless, self-accusatory and show delusions of persecution." The delusional ideas are depressive, extravagant and hypochondriacal. "They have offended everybody; are eternally damned; Satan is coming and will take them; he is out there. Nature has changed, everything is different, no mercy can come from heaven; there are ghosts in the house; the patients find themselves in the infernal regions, are surrounded byhostile powers, are in a bewitched castle. They will be carried away, thrown into a fiery furnace, their arms and legs cut off, have their throats cut in the presence of a thousand students, and be buried alive. They have a cancer in the stomach, the husband is insane or has had a stroke." Suicidal attempts are frequent. Sometimes grandiose ideas are expressed, accompanied by hallucinations. Apprehension and orientation are usually not disturbed. This is ordinarily followed by a period of violent excitement with agitated wringing of the hands, striking the breast, tearing the hair, etc. Confusional conditions with clouding may appear, often terminating shortly in a pneumonia, erysipelas or heart failure. According to Nissl, widespread and well marked changes are to be found in the brain at autopsy. There is an extensive destruction of ganglion cells, although that cannot be definitely associated with the symptoms of the disease. Kraepelin leaves the question open as to whether this should be looked upon as some form of "acute delirium" such as manifests itself in the course of various psychoses. The disease is usually one of the sixth decade of life, much more common in the female sex, and cannot without further information be definitely excluded from the involutional processes. He concludes his discussion by saying that these conditions probably "have some relation to the similar delirious senile forms to be discussed later." This is, of course, a decided modification of his original views, although it is quite clear that he still feels that there is an involutional depression, now included, however, in the presenile group.
In his chapter on manic-depressive insanity three years later Kraepelin[288]referred to this question again as follows:—"Under these circumstances I thought at first that the involutional depressions described as special clinical forms, melancholia in the narrower sense,which seemed to show essential differences in its general characteristics, course, and to a certain extent in the history of its development, should be separated from manic-depressive insanity. At the same time I was aware of the fact that in a considerable number of the involutional depressions, both on account of their clinical form and their association sooner or later with manic states, their connection with manic-depressive insanity could not be questioned. I therefore made an effort to establish a practical differentiation, entirely without satisfactory results. Further experience has demonstrated, as was shown in the discussion of the presenile psychoses, that they do not constitute grounds for the separation of melancholia. Deterioration is explained by the development of senile or arteriosclerotic changes. Some cases were of long duration, showing manic symptoms before recovery. The frequency of depressions in advanced years we have learned to be a legitimate development of the involutional period of life. The substitution of anxious excitement for volitional inhibition has proved to be an occurrence which is found in advancing years in those cases which had an attack of the ordinary form in the decade before (as shown in our cases 1 and 2). Hübner has, moreover, made the observation that melancholia may show retardation in one attack and not in the next. There remains, therefore, no adequate reason for differentiating the involutional depressions heretofore described as melancholia from manic-depressive insanity."
Kehrer[289]has made a careful analysis of the facts brought out by Kraepelin's statistical diagram showing the various age groups represented by his manic-depressive cases. "From the fifteenth year of life, at which age manic and melancholic attacks are most frequent (about twenty-five per cent), the curve of the manicattacks falls steadily (with only two important rises at the thirty-fifth and the forty-fifth years) until it becomes less than five per cent at the seventieth year, while the curve of the melancholic conditions with equal constancy increases (with the exception of the fifty-fifth year only), especially between the forty-fifth and fiftieth years, from fifty-two to seventy-four per cent and finally to eighty per cent. On the other hand, the curve of the manic first attacks falls steadily from 28.5 per cent at the twentieth year to 3.5 per cent at the sixtieth, with a slight increase at fifty from 12.7 per cent to 13.4 per cent, while in the male sex the same curve shows no further increase after the thirtieth year, when it reaches its maximum (33.8 per cent) and even shows a particularly sharp fall, from 22.2 per cent to 5.9 per cent, between the fiftieth and sixtieth year.... Based on this diagram Kraepelin concluded that the depressions of the involutional period, which did not show special symptoms of some other disease entity, could not be differentiated from those of the earlier periods of life."
Specht,[290]Hübner and Stransky have subscribed to these views. Stransky expressed the opinion that "there is nothing in the form of these depressions, either with or without anxiety, by which they can be distinguished from those recognized as manic-depressive insanity and that neither the course nor the age of onset offer any convincing argument for their clinical independence." Rehm, on the other hand, held that there were depressions of the involutional period of life corresponding to Kraepelin's melancholia and not belonging to manic-depressive insanity. He described these as lacking the constitutional taint and characterized by a slow onset, without previous attacks, fatigability, outspoken egocentric conduct, hypochondriacal delusions of the deteriorative type and theappearance of hallucinations. Bleuler,[291]Bumke, Seelert, Albrecht and others still hold to the integrity of involution melancholia as a distinct entity. "These forms," as Bleuler expresses it, "have as a rule a much more protracted course. They progress slowly for one or two years, continue to be mild, reaching their height in several years, and decline slowly to their final conclusion. The inhibition is obscured by great restlessness, genuine agitated forms are common, they tend to recidivism much less than the others and show also much less heredity." Albrecht, in 138 cases of functional psychoses of the involutional period, only thirty-two of which were in men, diagnosed eighty-two as genuine involution melancholia. In none of his cases did he find an isolated attack of mania in that period of life. He differentiates this condition from agitated melancholia, leaving the question open as to whether this constitutes a pernicious form or is a presenile disease. According to Bumke, psychic causes are more prominent in involution melancholia than in the manic-depressive psychoses, the duration is longer and they do not make such complete recoveries, the most common termination being a depressive mental enfeeblement, with despondency and an anxious hypochondriacal mood. For the genetic interpretation of climacteric melancholia as well as the other involutional forms the intimate association, according to Bumke, of endogenous with exogenous factors is the point of greatest importance. "Involution only brings the barrel to an overflow; it only adds exogenous to the individual endogenous momentum so that the sum total leads to the outbreak of a manifest psychosis." Seelert goes still further with the endogenous exogenous theory of Bumke. "It depends on the type of the association whether the organic anxiety psychosis, a melancholia or the depression of a manic-depressiveinsanity develops in the later period of life. In one the endogenous factors predominate, in the other the exogenous and in melancholia (in its narrower sense) the two maintain a balance."
Although, as has been noted, no characteristic pathological changes have been associated with involutional melancholia, a condition to which attention was called by Adolf Meyer should be referred to here. In 1901, in an article in "Brain" on "The Parenchymatous Systemic Degenerations mainly in the Central Nervous System" he proposed the name "Central Neuritis" for a terminal affection previously described by Turner in 1899 and occurring more frequently perhaps in involutional melancholia than in any other psychosis:—"This alteration has been found to occur in peculiar forms of end stages of depressive disorders, near or after the climacteric period, alcoholic-senile and alcoholico-phthisical cachectic states, idiocy, and perhaps also general paralysis (Turner's case). Ordinary infectious and cachectic states do not, however, appear to form an important link in the causes."[292]The mental condition is usually anxious, agitated and apprehensive, often terminating in a delirium followed by a stupor. The disease may last for a few days ending in death or may recover after several weeks. It is accompanied by progressive weakness, loss of weight and wasting, a slight rise of temperature, and in many cases attacks of diarrhea. Characteristic are muscular tension with rigidity, twitching movements, incoordination and jactitation of the limbs. The reflexes are usually increased. The onset is often quite sudden, usually in the fourth, fifth or sixth decade of life. At autopsy a striking condition, described as axonal alteration, is found in the "Betz" and other large ganglion cells generally. The cell body is somewhatswollen, the stainable substance is reduced to a structureless powder and the nucleus is dislocated and appears conspicuously in the periphery. There is also some "Marchi" degeneration of the fibre tracts in the motor areas. The regions involved, according to Meyer,[293]are "the cortico-thalmic connections of the motor areas, the auditory radiation, the forceps, the pyramids, the fillet, the restiform body, and to a lesser degree, the posterior column of the cord, the intersegmental elements, and the segmental efferent motor elements."
In view of the attitude of the psychiatrists of this country as shown by numerous expressions of opinion, the statistical committee of the Association felt justified in retaining involution melancholia in its classification of psychoses for the present and collecting data for further consideration. The following suggestions were offered as to its delimitation:—
"These depressions are probably related to the manic-depressive group; nevertheless the symptoms and the course of the involution cases are sufficiently characteristic to justify us in keeping them apart as special forms of emotional reaction.
"To be included here are the slowly developing depressions ofmiddle life and later yearswhich come on with worry, insomnia, uneasiness, anxiety and agitation, showing usually the unreality and sensory complex, but little or no evidence of any difficulty in thinking. The tendency is for the course to be a prolonged one. Arteriosclerotic depressions should be excluded.
"When agitated depressions of the involution period are clearly superimposed on a manic-depressive foundation with previous attacks (depression or excitement) they should for statistical purposes be classed in the manic-depressive group."
In view of the history of the development of the conception of this psychosis an analysis of the hospital statistics on this subject is of unusual interest. We now have reports of over seventy thousand first admissions based almost entirely on the classification at present used by the Association. In 49,640 first admissions to the New York hospitals during a period of eight years there were 1,351 cases diagnosed as involution melancholia—2.72 per cent of the total. During 1918 and 1919, when the Association's classification was followed in detail, these hospitals showed 480 cases, or 3.45 per cent of 13,588 first admissions. Twenty-one public institutions in fourteen other states reported 378 cases, or 2.06 per cent of 18,336 admissions. Two and twenty-five hundredths per cent of the admissions to the Massachusetts state hospitals in 1919 were cases of involution melancholia. Reports from forty-eight different state hospitals show that involution melancholia constituted 2.53 per cent of over seventy thousand admissions. This shows a remarkable similarity in standards of diagnosis as far as this psychosis is concerned.