Kraepelin[159] describes first a group of presenile cases showing the development of depressive ideas and anxious states with a progressive mental enfeeblement. Delusions of self-accusation and persecution present themselves early in the course of the disease. Symptoms of a more decidedly hypochondriacal type may occur later. Hallucinations and somatic delusions also develop, often with nihilistic trends. Everyone is dead, the patient is the only one left in the world, has no legs, cannot go out of the house, has entirely disappeared, does not exist any more, etc. The consciousness is usually fairly clear, orientation is well preserved and there is no marked disturbance of thought. Anxious excitement is often an important feature. The termination is in mental enfeeblement invariably. This condition manifests itself usually at about the fortieth year. He is of the opinion that this symptom complex cannot be considered either as belonging to manic-depressive insanity or attributable to arteriosclerosis, nor is it catatonic in its origin. He finds another group of cases occurring in women between forty-five and fifty years of age, characterized pathologically by striking anatomical changes and clinically by a very unfavorable course. A depression first appears, followed by anxiety with thoughts of suicide. Hallucinations do not occur as a rule. Restless and agitated excitement is a prominent symptom leading finally to confusion, clouding of consciousness, and disorientation. This is followed by a condition of mental enfeeblement terminating in early death. Well-defined postmortem changes have been found, such as the "grave alteration" described by Nissl, proliferation of the glia, swelling of the protoplasmic bodies with cell enclosures, etc., but no fibril formation. Large quantities of lipoid material are found in the surrounding vessels and in the vascular sheaths. This condition, also observed by Nitsche and Döblin, Kraepelin looks upon as probably a presenile process of autotoxic origin, there being no other cause demonstrable. He does not consider this disease process as being related to "late katatonia," genuine katatonia or manic-depressive insanity. He would also separate out another smaller group as probably belonging to the presenile forms—cases with excitements of long duration, terminating in a marked deterioration. This condition is likely to be of sudden onset, with depressive ideas of self-accusation, later showing an active restlessness. These patients soon become clouded and confused, often with grandiose ideas suggesting general paresis. They may show memory falsifications. Stuporous states occasionally intervene, followed by an active excitement. Echolalia is common.