LECTURE III.

STATES OF MENTAL DEPRESSION-MELANCHOLIA

(PSYCHALGIA)-CONTINUED.

Excited (Motor) Melancholia.-This, like all the other varieties of the disease, may be one stage in the complete clinical history of a case, or may be the type from beginning to end. The motor centres are evidently affected to a greater extent in this than in any of the other varieties, except the one I shall describe as the melancholia with epileptiform attacks. The patients rush about, are violent to those about them, wander ceaselessly, walking up and down like tigers in a cage, or roll about on the floor, or wring their hands, or shout, or groan, or moan, or weep loudly, or tear their clothes, or in their cries, attitudes, and motions express strongly their mental pain. In short, the muscular expression of the pervading emotion is strong and uncontrollable by volition. Some of the very worst and most incurable cases of melancholia are of this type-certainly the most troublesome to manage. The motor expressions are partly determined by the intensity with which the ideo-motor centres are affected in the brain, and partly by the amount of inhibition possessed by the individual when well. Women very frequently present the motor type of the disease. The Celtic race does so markedly. The wailing and weeping, the gesticulations and motor grief of an Irish woman are usually out of all proportion to the mental pain—that is, if we take the Teutonic type as our standard. Here is an example:

A. V., æt. 28, an Irish woman. Patient had been confined a week previous to admission. The day before her admission she suddenly became very unsettled and careless about her child; she also attempted suicide. On admission she was

greatly depressed; she confessed to feeling exceedingly miserable, and could only be got to answer the simplest questions with difficulty; she had a woe-begone appearance, and her bodily health was very weak. She slept very little the first night, but seemed considerably better next day; conversed readily and cheerfully; said she felt much better, and that her strange behaviour previous to admission was due to something which came over her and confused her.

In a week she got worse, being much depressed; thought she was to be killed, and that everything was going wrong with her; did not take her food well; attempted to drown herself by jumping into the asylum shallow curling pond.

In a month she was somewhat improved, but still continued much depressed in mind. She did a little work. In six weeks, after seeming to improve for a time, patient relapsed. She became the embodiment of utter misery and wretchedness, which she exhibited in a most demonstrative way. She wrings her hands; sways backwards and forwards, contorting her body; rushes about from place to place, and cannot settle for a minute. But the most striking things about her are her countenance and the noises she makes. She has a large mouth, and as her visage assumes the most doleful aspect, expressing the intensest misery, her mouth begins to open until it is a great gaping cavern, and she howls-"Oh, John dear! doctor, darlin'! and me childer! and me presecuted in this jail! oh, I'm punished! dear darlin' doctor! oh, me two brothers! oh, kilt and murdered they are! Oh! oh! oh!" All this time there is seldom a tear, and it goes on from morning till night, and sometimes all night, so that you cannot hear yourself speak within 10 yards of her. Though the misery is most real to her, yet the effect is often very ludicrous, as if you were looking at the overdone misery of an Irish wake on the stage. She ate well, and her bodily health improved, though she had prolapsus uteri, for which no treatment could be adopted.

Here is a chronic case of the sort that has gone on for years:

A. W., æt. 45, deaf and dumb, who was educated. A relative is insane.

For four years now he has been in his present condition, which to all outward appearance is that of misery, as great as any painter has ever depicted as the lot of the damned in hell. He is never at rest, but paces about with an uneasy nervous gait. His hands are always moving, tearing his clothes or unbuttoning them, or masturbating, which he does in the most shameless open way; indeed, he is doing it half the time. He makes a hideous noise nearly all the time between a groan and a hiss, and his expression of face is that of absolute misery and desperation. At times he rushes about, and if any one comes in his way he knocks him down; in fact, he has a distinct homicidal impulse, which makes him attack those near him. At times he tears his flesh and beats his head. He seems to feel no pain. He is the worst patient in Morningside Asylum, and, in fact, is about the worst I have ever seen, taking the long time he has been affected into account. Everything has been tried in vain for his recovery and amelioration. Nothing will interest him; scarcely anything will quiet him. I have tried hyoscyamine, and it nearly poisoned him. I gave him bromide of potassium in doses up to 6 drachms a day. I tried cannabis Indica with it, and he merely fell off in flesh, without being benefited. He was walked in the fresh air till two strong attendants were done up. He was tried to wheel heavy barrows of soil, but the fight to get him to do so threatened to run some risk of killing him. I only wish I could castrate him, for the constant masturbation, or attempt to masturbate, seems to show that the centres of generation are in a state of morbid excitation, and I think it might do him good.

This is another chronic case of motor melancholia, which is very common in old age :—

A. X., æt. 77. Single; gentlewoman. Disposition active, but passionate. First attack. No exciting cause known. Had a fall down stairs six months ago. Became very restless and sleepless, and lost appetite. This condition has lasted for three months.

On admission she was very depressed and unsettled. Could not sit down or rest for a moment. Walked about the room the picture of despair, and took no interest in anything. Was enfeebled in mind, and behaved in a silly, miserable way. Her physical condition and general health were poor, and she was very anxious about her state of health and her soul's salvation. She had no sleep the night after admission, and was very noisy and restless. She was very depressed; begged to be sent home; wrung her hands and wept. This continued with little change. Her nights, with few exceptions, were sleepless, unless narcotics were given; and she was also very noisy, beating at her bedroom door and shouting loudly. During the day she was in a constant state of miserable unrest. She was suspicious and despondent; said she wished she were dead; refused her food; would not settle to any work. This state of unhappy restlessness and excitement became fixed and chronic, while her mind became more enfeebled. She got plenty of food, but never could be fattened. After three years she began to show distinct signs of partial hemiplegia, which was first on one side and then on the other, each attack passing off in a few days. Two of my former assistants, Drs Hayes Newington and J. J. Brown, have described this condition and its pathology, attributing it to capillary apoplexies, as are shown in Plate VII. fig. 2, occurring in succession.1 But she could never sit down for any length of time till near the very end, a year after the commencement of the paralysis, when she went to bed and soon died. She would eat her meals standing and moving. She swore and used blasphemous language to herself. She said she would "burst" if she was made to sit down. The convolutional motor excitement was unceasing, and nothing could exhaust it. It was connected with the decay and degeneration and atrophy of the brain in old age-a long-continued brain storm that ended only with life. Such old people are most difficult to treat. If we, by mechanical means, restrain their 1 Edin. Med. Jour., August 1874, and Jour. of Mental Science, July 1877.

motions, my experience has been that it is no conservation of energy, but the excitement, finding no motor outlet, reacts inwards and makes the mental state much worse.

When insanity in boys and girls takes the melancholic form, it is usually attended by much motor excitation, especially weeping the boyish mode of expressing grief. This is an example :

A. Y., æt. 12. Disposition: old-fashioned, sedentary, excitable, thoughtful, and studious for his age. Several brothers and sisters died in infancy of head affections, and a paternal uncle had been melancholic. Mother nervous and eccentric. Father died of consumption. Had been brought up in a poor way with an old grandfather, with whom he lived alone, living on tea and coffee and no milk. Had not romped and played enough. Had been in the habit of wetting the bed. His father died a few months ago, Seemed to feel it as a man would, and has never been the same since. Of late has dreamed much, and awoke in the middle of the night. Has been at school, and did well. Last week the schoolmaster checked him for holding his pen the wrong way. He came home agitated, nervous, depressed, and confused. Talked all night in an incoherent way of holding the pen, &c. He has got worse till he is now much depressed; crying, sometimes with tears, sometimes without, all the time. (By the way, melancholics are by no means always tearless. I have one now who literally weeps floods of tears.) He was most restless, sleepless, appetite gone; was flabby, with great dilated pupils; a temperature of 98°, and a pulse of 106, and weak. Under tinc. belladonæ gtt. x. and potas. bromid. gr. xv. twice a day, fresh air, milk, and light work, he rapidly improved, and was well in a fortnight. He wets the bed much less, too, when well. But in four months, when employed as a message boy, he began to fancy he was dishonest; got confused, crying badly, was depressed and nervous, and dreamed terrible dreams. He got well, and then relapsed. His tendency to recurrence, and relapse is characteristic of all the mental diseases in, and of all the neuroses of,