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Originally appearing in Volume V14, Page 603 of the 1911 Encyclopedia Britannica.
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MELANCHOLIA.—Melancholia is a general term applied to all forms of insanity in which the prevailing mental symptom is that of depression and dates back to the time of netan- Hippocrates. Melancholic patients, however, differ chotla- very widely from one another in their mental symptoms, and as a consequence a perfectly unwarrantable series of sub-divisions have been invented according to the prominence of one cr other mental symptoms. Such terms as delusional melancholia, resistive melancholia, stuporose melancholia, suicidal melancholia, religious melancholia, &c. have so arisen; they are, however, more descriptive of individual cases than indicative of types of disease. So far as our present knowledge goes, at least three different and distinct disease conditions can be described under the general term melancholia. These are, acute melancholia, excited melancholia and the state of depression occurring in Folie circulaire or alternating insanity, a condition in which the patient is liable to suffer from alternating attacks of excitement and depression. Acute Melancholia is a disease of adult life and the decline of life. Women appear to be more liable to be attacked than men. Hereditary predisposition, mental worry, exhausting occupations, such as the sick-nursing of relatives, are the chief predisposing causes, while the direct exciting cause of the condition is due to the accumulation in the tissues of waste products, which so load the blood as to act in a toxic manner on the cells and fibres of the brain. The onset of the disease is gradual and indefinite. The patient suffers from malaise, indigestion, constipation and irregular, rapid and forcible action of the heart. The urine become scanty and high coloured. The nervous symptoms are irritability, sleeplessness arid a feeling of mental confusion. The actual onset of the acute mental symptoms may be sudden,and is not infrequently heralded by distressing hallucinations of hearing, together with a rise in the body temperature. In the fully developed disease the patient is flushed and the skin hot and dry; the temperature is usually raised 1° above the normal in the evening. The pulse is hard, rapid and often irregular. There is no desire for food, but dryness of the mouth and tongue promote a condition of thirst. The bowels are constipated. The urine is scanty and frequently contains large quantities of indoxyl. The blood shows no demonstrable departure from the normal. The patient is depressed, the face has a strained, anxious expression, while more or less mental confusion is always present. 'Typical cases suffer from distressing aural hallucinations, and the function of sleep is in abeyance. Acute melancholia may terminate in recovery either gradually or by crises, or the condition may pass into chronicity, while in a small proportion of cases death occurs early in the attack from exhaustion and toxaemia. The acute stage of onset generally lasts for from two to three weeks, and within that period the patient may make a rapid and sudden recovery. The skin becomes moist and perspiration is often profuse. Large quantities of urine are excreted, which are laden with waste products. The pulse becomes soft and compressible, sleep returns, and the depression, mental confusion and hallucinations pass away. In the majority of untreated cases, however, recovery is much more gradual. At the end of two or three weeks from the onset cf the attack the patient gradually passes into a condition of comparative tranquillity. The skin becomes moister, the pulse less rapid, and probably the earliest symptom of improvement is return of sleep. Hallucinations accompanied by delusions persist often for weeks and months, but as the patient improves physically the mental symptoms become less and less prominent. If the patient does not recover, the physical symptoms are those of mal-nutrition, together with chronic gastric and intestinal disorder. The skin is dull and earthy in appearance, the hair dry, the nails brittle and the heart's action weak and feeble. Mentally there is profound depression with delusions, and persistent or recurring attacks of hallucinations of hearing. When death occurs, it is usually preceded by a condition known as the " typhoid state." The patient rapidly passes into a state of extreme exhaustion, the tongue is dry and cracked, sordes form upon the teeth and lips, diarrhoea and congestion of the lungs rapidly supervene and terminate life. Treatment.—The patient in the early stage of the disease must be confined to bed and nursed by night as well as day. The food to begin with should be milk, diluted with hot water or aerated water, given frequently and in small quantities. The large intestine should be thoroughly cleared out by large enemata and kept empty by large normal saline enemata administered every second day. Sleep may be secured by lowering the blood pressure with half-grain doses of erythrol-tetra-nitrate. If a hypnotic is necessary, as it will be if the patient has had no natural sleep for two nights in succession, then a full dose of paraldehyde or veronal may be given at bed-time. Under this treatment the majority of cases, if treated early, improve rapidly. As the appetite returns great care must be taken that the patient does not suddenly resume a full ordinary dietary. A sudden return to a full dietary invariably means a relapse, which is often less amenable to treatment than the original attack. Toast should first be added to the milk, and this may be followed by milk puddings and farinaceous foods in small quantities. Any rise of temperature or increase of pulse-rate or tendency to sleeplessness should be regarded as a threatened relapse and treated accordingly. Excited Melancholia.—Excited melancholia is almost invariably a disease of old age or the decline of life, and it attacks men and women with equal frequency. Chronic gastric disorders, deficient food and sleep, unhealthy occupations and environments, together with worry and mental stress, are all more or less predisposing causes of the disease. The direct exciting cause or causes have not as yet been demonstrated, but there is no doubt that the disease is associated with, or caused by, a condition of bacterial toxaemia, analogous to the bacterial toxaemias of acute and chronic rheumatism. 'The onset of the disease is always gradual and is associated with mal-nutrition, loss of body weight, nervousness, depression, loss of the capacity for work, sleeplessness and attacks of restlessness. These attacks of restlessness become more and more marked as self-control diminishes, and as the depression increases the disease passes the borderland of sanity. In the fully developed disease the appearance of the patient is typical. The expression is drawn, depressed, anxious or apprehensive. The skin is yellow and parchment like. The hair is often dry and stands out stiffly from the head. The hands are in constant movement, twisting and untwisting, picking the skin, pulling at the hair or tearing at the clothes. The patient moans continuously, or emits cries of grief and wanders aimlessly. Mentally the patient, although depressed, miserable and self-absorbed, is not confused. There is complete consciousness except during the height of a paroxysm of restlessness and depression, and the patient can talk and answer questions clearly and intelligently, but takes no interest in the environment. Some of the patients suffer from delusions, generally a sense of impending danger, but very few suffer from hallucinations. Physically there is loss of appetite, constipation and rapid heart action, a great increase in the number of the white blood corpuscles, particularly of the multinucleated cells which are frequently increased in bacterial infections. In the blood serum also there can be demonstrated the presence of agglutinines to certain members of the streptococci group. The course of the disease is prolonged and chronic. The acute symptoms tend to remit at regular intervals, the patient becoming more quiet and less demonstratively depressed; but as a rule these remissions are extremely temporary. Excited melancholia is a disease characterized by repeated relapses, and recoveries are rare in cases above the age of forty. Treatment.—There is no curative treatment for excited melancholia. The patient must be carefully nursed; kept in bed during the exacerbations of the disease and treated with graduated doses of nepenthe or tincture of opium, to secure some amelioration of the acute symptoms. Careful dieting, tonics and baths are of benefit during the remissions of the disease, and in a few cases seem to promote recovery. Folie circulaire, or alternating insanity, was first described by Falret and Baillarger, and more recently Kraepelin has considerably widened the conception of this class of disease, which he describes under the term " manic-depressive insanity." Of the two terms (folie circulaire and manic-depressive insanity) the latter is the more correct. Folie circulaire implies that the disease invariably passes through a complete cycle, which description is only applicable to very few of the cases. Manic-depressive insanity implies that the patient may either suffer from excitement or depression which do not necessarily succeed one another in any fixed order. As a matter of fact, the majority of patients who suffer from the disease either have marked excited attacks with little or no subsequent depression, or marked attacks of depression with a subsequent period of such slight exaltation as hardly to be distinguished from a state of health. Depression of the manic-depressive variety, therefore, may either precede or follow upon an attack of maniacal excitement, or it may be the chief and only obvious symptom of the disease and may recur again and again. The disease attacks men and women with equal frequency, and as a rule manifests itself either late in adolescence or during the decline of life. Hereditary predisposition has been proved to exist in over 50 % of cases, beyond which no definite predisposing cause is at present known. A considerable number of cases follow upon attacks of infective disease such as typhoid fever, scarlet fever or rheumatic fever. The actual exciting cause is probably an intestinal toxaemia of bacterial origin; at all events, mal-nutrition, gastric and intestinal symptoms not infrequently precede an attack, and the condition of the blood—the increase in number in the multinucleated white blood corpuscles and the presence of agglutinines to certain members of the streptococci group of bacteria—are symptoms which have been definitely demonstrated by Bruce in every case so far examined. If the depression is the sequel to an attack of excitement, the onset may be very sudden or it may be gradual. If, on the other hand, the depression is not the sequel of excitement, the onset is very gradual and the patient complains of lassitude,incapacity for mental or physical work, loss of appetite, constipation and sleeplessness often for months before the case is recognized as one of insanity. In the fully developed disease the temperature is very rarely febrile, on the contrary it is rather subnormal in character. The stomach is disordered and the bowels confined. The urine is scanty, turbid and very liable to rapid decomposition. The heart's action is slow and feeble and the extremities become cold, blue and livid. In extreme cases gangrene of the lower extremities may occur, but in all there is a tendency to oedema of the extremities. The skin is greasy, often offensive, and the palms of the hands and the soles of the feet are sodden. Mentally there is simple depression, without, in the majority of cases, any implication of consciousness. Many patients pass through attack after attack without suffering from hallucinations or delusions, but in rare cases hallucinations of hearing and sight are present. Delusions of unworthiness and unpardonable sin are not uncommon, and if once expressed are liable to recur again during the course of each successive attack. The disease is prolonged and chronic in its course, and the condition of the patient varies but little from day to day. When the depression follows excitement, the patient as a rule becomes fat and flabby. On the other hand, if the illness commences with depression, the chief physical symptoms are mal-nutrition and loss of body weight, and the return to health is always preceded by a return of nutrition and a gain in body weight. The attacks may last from six months to two or three years. The intervals between attacks may last for only a few weeks or months or may extend over several years. During the interval the patient is not only capable of good mental work but may show capacity of a high order. In other words this form of mental disorder does not tend to produce dementia; the explanation probably being that between the attacks there is no toxaemia. Treatment.—There is no known curative treatment for the de. pression of manic-depressive insanity, but the depression, the sleeplessness and the gastric disorder are to some extent mitigated by common sense attention to the general health of the body. If the patient is thin and wasted, then treatment is best conducted in bed. The diet should be bland, consisting largely of milk, eggs and farinaceous food, given in small quantities and frequently. Defecation should be maintained by enemata, and the skin kept clean by daily warm baths. What is of much more importance is the fact that in some instances subsequent attacks can be prevented by impressing upon the patient the necessity for attending to the state of the bowels, and of discontinuing work when the slightest symptoms of an attack present themselves. If these symptoms are at all prominent, rest in bed is a wise precaution, butcher-meat should be discontinued from the dietary and a tonic of arsenic or quinine and acid prescribed.
End of Article: MELANCHOLIA
MELANCHLAENI (from Gr. µEtas, and Xtaiva, " Black-...
MELANCHOLY (Gr. µe)tayXotia, from µEtas, black, a...

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