reproach and threaten him, or the sounds of machinery and other tortures which are being prepared to cut him up or mutilate him ; smells and tastes horrible things, and so on.

Next to the affect of depression, the most noteworthy symptom of melancholia is the slowing of the thought processes. This is the antithesis of the accelerated flow of thought noted in maniacal conditions.

The processes of memory are retarded, and the attention of the patient difficult to gain. A minute or several minutes are required for the answer to the simplest question. Sometimes no answer is given at all, or at most the lips stir inaudibly.

The contents of the concepts may, in milder degrees, show no delusions. More often the patient attempts to explain his feeling of abject misery and distress either by the presence of some fancied physical ailment (hypochondriacal melancholia, with delusions of having syphilis, consumption, cancer, impotence, incurable disorders of the stomach, bowels, etc.), or as the result of some sin of his past life. To the delusion of having sinned an especial color is given by the character of the patient's early education. Thus, a strong religious bias gives rise to delusions of having committed the unpardonable sin, of being doomed to hell, to everlasting punishment, to be buried alive, etc. Often such delusions are connected with some trivial error of his past life. For instance, a patient of mine recently told me, "I once chloroformed a dog to death and buried him. I think now I made a mistake in not making positively sure that the dog was dead, and as a result I am doomed to be buried alive also, and to be tortured with dreadful thoughts through eternity, each day the torture growing more dreadful, up to the decillionth power of intensity."

Patients often say they are not sick, they are only wicked. They have committed sins not only against God, but against society. Not only must they undergo the punishment ordained by Heaven, but they must answer to man for infringements of human law. They are to be put in prison, to be killed, to be hung. Thus they come to delusions which are somewhat similar to persecutory ideas in that they believe the officers of the law are after them, etc. These differ, however, from the true persecutory delusions in which patients have no self-depreciatory ideas, but believe themselves to be the innocent victims of inimical conspiracies. Delusions of poverty are very common, and especially so in senile melancholia.

The conduct of the melancholiac depends upon the contents of his consciousness. In his expression we note the lines of extreme depression, or of fear and terror. The patient with the delusion of sin or poverty, for example, presents motor inhibition. He sits in one place with head bowed down, unmindful of what goes on about him, indifferent or apathetic to all questions put to him, resisting every attempt to give him food or medicine, or to dress and undress him, or to give him exercise. He is lost in the contemplation of his misery. Another patient, with these or similar depressed ideas more accentuated, or with marked hallucinations, will wring his hands, tear his hair, walk or run up and down, bewailing his misfortunes, or seeking to escape the

dreadful fate in store for him. In the first case the motor inhibition may be so complete as to make the patient perfectly immobile, so that not a single voluntary movement is made; even micturition and defecation are involuntary. Such immobility is generally of flaccid character, but sometimes it assumes the phase of rigidity, a waxy flexibility, or a

Fig. 273. Catatonic symptoms in various psychoses (melancholia, general paresis, circular insanity, primary dementia, etc.) (photograph loaned by Dr. Atwood, of Bloomingdale).

spasmodic resisting rigidity (catatonic rigidity). Catatonic symptoms have been noted in other forms of psychoses, but the disorder described by Kahlbaum under the name catatonia is really a form of melancholia. Suicidal tendencies are observed in every type of melancholia, but especially in those with precordial distress and agitation. In the milder

degrees, an attempt at suicide is often the first intimation to friends of the actual existence of insanity, since in these cases, outside of the sorrowful mood of the patient, the intellectual processes may go on as before. Cases of melancholia attonita (with marked motor inhibition) also often make attempts at suicide, unexpected explosive attempts, the result of the sudden letting up of mental and bodily tension. This has been called the raptus melancholicus. Homicidal attempts and violent assaults are occasional in melancholia. A melancholy mother kills her children to put them out of an unhappy world. Or a sudden dangerous assault is made as an explosion of motor tension. Hypochondriacal melancholiacs may mutilate themselves. Patients with melancholia have also been known to enter upon alcoholic excesses to drown their misery; this is especially observed in periodical melancholia. The refusal of food is almost the rule of conduct in all forms of melancholia. Sometimes this refusal rests upon a delusional foundation: the patient

thinks he can not digest his food, that it never passes through him, that he is too poor to pay for it, that he is too wicked to eat, that he must do penance, and so on. Or he refuses food with deliberate suicidal intent. Generally, profound anorexia, constipation, and gastro-intestinal disorders are at the basis of this refusal to eat.

Physical Symptoms.-The pulse is usually subnormal in frequency, though sometimes, especially in agitated forms, accelerated. The peripheral arteries are contracted and the extremities cold. The respiration is retarded and superficial, as a rule, though it may be increased in the agitated types. Sleep is much disordered, and even altogether absent, in severe cases. The patient emaciates both through refusal of food and because of disordered digestion. The gastric juice and saliva are often diminished in quantity. The tongue is foul and furred, and obstinate constipation is present. result of constipation, elevations of temperature may be observed, but otherwise the temperature is undisturbed. The surface temperature in the extremities is often much reduced. Amenorrhea is frequently induced by melancholia as well as by mania.

As a

Varieties. As in the case of mania, we distinguish acute, subacute, and chronic forms of melancholia; acute and subacute according to the degree and rapidity of inception, chronic from the duration.

Melancholia passiva is a term used to describe the cases with great motor inhibition of the flaccid order.

Melancholia attonita designates the type with motor tension and rigidity.

Melancholia agitata is a name used for melancholia with motor excitement.

Acute hallucinatory melancholia is the form accompanied by numerous illusions and hallucinations.

Hypochondriacal melancholia is melancholia associated with delusions as to physical maladies.

Raptus melancholicus is a phrase employed to describe the furious outbreaks of violence toward the patient himself or others, on the sudden cessation of mental and motor tension.

Catatonic melancholia,1 already alluded to, is not a distinct type of mental disease, but simply a modification in the course of melancholia. It has often been considered as a special form of psychosis, and many alienists have argued pro and con. the question of its being a clinical entity. It is a very rare syndrome. A perfectly typical case is the following, observed by me in the Hudson River State Hospital :

CASE I.-B. R., female; age thirty-one; married, with four children; Hebrew; common education; born in United States; admitted to the Hudson River State Hospital in February, 1884; no heredity.

The first evidence of mental disturbance was in August, 1883, after the birth of her last child, which she nursed for two months, when she became sleepless, restless, and inclined to refuse food. Soon she developed the idea that she would never recover, began to bemoan her condition, and said it was hard to die so young. There was complete anorexia. She took no interest in anything, became careless of her person and dress and negligent of everything in which she had formerly been interested. Three weeks before admission she became suicidal, spoke of it, and attempted to choke herself and to cut herself with glass. She would bite her caretakers, and took every means possible to make away with herself. Her menstruation was regular. There was considerable constipation. The case was regarded as one of puerperal melancholia.

February 11th, two days after admission, she tried to beat her head against the bedstead; said some one was killing her children and putting them in a box; said arsenic was put in her coffee and that her mother was in the asylum; was sleepless and had to be fed forcibly. She became rapidly worse during the next few days; went into a condition of noisy excitement, calling for her mother, whom she believed to be in the building; mentioned her delusions of poisoning, beat and bruised herself against the bedstead, and refused all food. She was very suicidal. Her mouth and tongue became dry; she showed symptoms of exhaustion and was fed with the tube for a considerable period. She continued to refuse food, to resist all care strenuously, and to be desperately suicidal until March 15th, when she became cataleptic, with marked flexibilitas cerea; absolutely silent; noticing nothing, not even her husband, who visited her; would swallow food put in her mouth; made no voluntary motions; pulse good; bowels moved by enemata, but began to wet and soil the bed, and as she grew stronger was looked upon as rapidly becoming demented. This state of catalepsy continued, with variations

"Catatonia," by Frederick Peterson, M.D., and Charles H. Langdon, M.D., "Proceedings of the Amer. Medico-Psychological Assoc.," Baltimore, 1897.

from time to time, for a month or more, when she began to be destructive of her clothing, would strip herself naked, and was filthy in her habits. She remained in that condition, seldom uttering a word for months, until about the last of November, 1884, when she began to cry out loudly, "Bring me home to my children in New York. Bring me home to my children in New York," reiterating this over and over from morning until night, and accompanying the phrase with rhythmic movements of the hands and arms as if she were waving them in the direction she wished to go. There was a rhythm in the days, too, for every alternate day she was quiet in her chair and would whisper. This continued without variation for some two months, during all of which time she was eating and sleeping well and gaining in flesh.

About the middle of January, 1885, her verbigeration took another character, the gesticulations remaining the same. She began to recite all day long, every other day, with great rapidity and with infinite variation, in rhymes of unintelligible words, as follows:

and so on, ad infinitum. She only changed to another word when the possibilities of rhyme were exhausted.

She was mentally confused. When asked why she made these rhymes she said some one told her to; but this was probably an answer given because she could not explain why, for she had now no hallucinations or delusions. She was so confused that she did not feel sure it was her husband who came to see her.

A few months later she gave up the rhyming assonances and returned to the old phrase, with occasional variations, "I want to go home to my children in New York." "Won't I be glad when I get home to my children in New York." "What good times I'll have when I get home to my children in New York to my cosy home in New York when I get into the car which takes me to my husband and children in New York." This was the refrain for many months on alternate days, accompanied as before with rhythmic gestures of both arms in the supposed direction of New York. In the spring of 1886, on the quiet, alternate days, she began to sew. She steadily improved in flesh and was looked upon as in a state of dementia. There was no appreciable change in her condition during the summer. The verbigeration and gesticulation alternated with quiet and industrious days until the autumn of 1886, when improvement began to manifest itself in every way, and in November she was discharged as improved and went home with her husband on trial. There she recovered perfectly so that not a vestige of the insanity remains, and she is to this day