A system of practical medicine. By American authors. Vol. 5

by Unknown

Acute melancholia is sometimes confounded with delusional insanity with mental depression. In the former the delusions are evolved from the mental state; in the latter, the mental state from the delusions. In the former the delusions are for the most part unsystematized: the patient cannot state why he believes them to be true; in the latter there is correct reasoning from false premises: the delusions are logical or systematized and of a depressing character, so that a belief in them naturally gives rise to sadness.

Before the courts the fact should be kept in mind that persons with acute melancholia have diminished power of self-control by virtue of their disease, and so yield more readily to temptation than in health. They also may have imperative conceptions—ideas so strong that they cannot, or can with difficulty, resist carrying them out even when they know them to be wrong; and there may be sudden outbursts of almost maniacal excitement. They are often able to make wills and perform contracts, in form and in detail, as well as ever, when they are so filled with insane delusions as to be on the point of killing themselves and their families. There is impaired capacity, however, of recognizing the relations of persons and things to one another, a distinct moral perversion, and a diminished recognition of obligations and sense of responsibility. In other words, they are not always fully themselves on those points in which they seem to be so, and yet patients in asylums with acute melancholia have been known to give the best of advice to their business-partners.

Melancholia with stupor (melancholia attonita) appears like complete dementia or a mindless state, but there are now and then evidences of intelligence. The mind is filled with overwhelming and terrible delusions, which paralyze the will and place mental and physical activity for a while in abeyance. It arises commonly in the course of the less profound form of melancholia, after some great mental shock, and there is a condition of marked anæmia of the brain, probably symptomatic rather than pathognomonic, which if not soon relieved goes on rapidly to atrophy and degeneration. Except when there are attacks of frenzy, which may occur at any time, there is little danger of active violent acts except suicide, desperate refusal of food, and determined resistance to any care or treatment. There are the usual indications of physical exhaustion.

In melancholia agitata the mind is clear and active, the opposite of the condition last described, and the distressing delusions produce such a degree of motor excitement arising from the mental suffering that the disease closely simulates acute mania. The mind not only reacts as readily as in health to distressing ideas, but abandons itself more fully to their domination through diminished will-power and lack of self-control. Almost blind acts of desperation and fury are committed from which the utmost vigilance can hardly save them.

The three severe forms of melancholia just described are interchangeable in the same person during the course of his illness, so that the states of frenzy and stupor are more properly called symptoms than classes of disease.

Melancholia among children is more common than the books state it to be, although rarely met in the asylums. Magnan has reported a suicidal case in a child four years old, and it occurs up to the latest years of life.

The DURATION of simple melancholia is from a few weeks to a dozen years; of acute melancholia, from a month to two or three years, after which it is apt to end in chronicity; melancholia stupida (with stupor) is usually curable, if at all, in the first year, although relapses are frequent, and in melancholia agitata from a year to three years is the common limit of the possibility of a cure.

The PROGNOSIS in simple melancholia is favorable. Including cases treated out of asylums, probably 90 per cent. recover; in acute melancholia, uncomplicated with other diseases, not far from two-thirds recover; in melancholia attonita less than half get well; and in melancholia agitata nominal recovery occurs perhaps in a third of the cases, although I doubt whether complete restoration to health is seen often.

In chronic melancholia the process of mental deterioration is slow. As the mind becomes impaired the delusions lose their activity and the mind reacts less readily, so that a state of less suffering and greater calm is reached, and the patients are often useful workers in asylums for many years, or remain in their own homes a constant source of anxiety to those who understand their condition. Many of them commit suicide.

In treatment of melancholia the first indication is to protect society and the individual against acts of violence. Homicidal acts are not to be feared in simple melancholia, unless in persons of bad character and ugly temper, or in those few cases with the symptoms, in addition, of moral insanity or impulsive insanity. Suicide is so rare that precautions will not often be needed against it, provided the patient is so frank or so transparent that the appearance of distinct delusions may be detected and then guarded against. In cases of long standing, especially in persons beyond middle age, this is extremely difficult, and their treatment outside of asylums must always be attended with risk. In the other forms of melancholia the fact should be taken for granted that the patient is suicidal, and he may be also homicidal, so that he should be watched constantly and efficiently, and never left alone or with weak or helpless persons, no matter how free from suicidal determination or impulse he may have appeared. The puerperal mother, especially, is a source of the greatest danger to her child, even when she seems natural and fond. The degree and kind of watching varies, according to the severity of the case, from the constant presence or close proximity of some responsible person, who may sleep in the same room with the usual home-surroundings, to the most vigilant and wakeful personal care every moment day and night, and removal of every source of possible self-injury. In some few cases this can be well done only in an asylum or in a padded room. Some form of restraint, either personal or by confining or limiting the movements of the hands in rare cases of exceptional desperation, will be found necessary.