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.