It will be noted that manic cases are more common than the depressive in New York, the number of the former being fifteen per cent greater than the latter. In Massachusetts the number of depressive forms is twenty-two per cent higher than the manic. In the other states the depressive types are less than five per cent higher than the manic. In all institutions the mixed forms are more common than the circular or stuporous. The stuporous forms constitute the smallest percentage reported in all hospitals, except in 1918 and 1919 in New York. We would be warranted, apparently, in the conclusion that in this country manic forms are the more common, the depressive being second in frequency, followed by the circular and stuporous types in the order mentioned.
The statement is, I think, also warranted that there is a considerable difference of opinion as to the classification of the different forms of manic-depressive insanity and that diagnostic procedure is far from being standardized. Many of these discrepancies are doubtless due to difficulties in differentiating between certain cases of manic-depressive psychoses and dementia praecox. The hospitals reporting lower percentages of the former usually show a much higher rate of the latter. Certainly there is room for an honest difference of opinion in many instances. It must be admitted, moreover, that our fundamental conceptions of these two great groups do not permit of a hard and fast line of demarcation between them in all cases.
CHAPTER XII
INVOLUTION 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 there was 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 played by 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 was to 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."