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INVOLUTION MELANCHOLIA.1
BY THOMAS J. CURRIE, M.D.,
Willard, N. Y.

TH

HIS term, as employed in the clinical study of insanity, corresponds practically to the older division of climacteric insanity, except that formerly the tendency was to include cases of maniacal outbreak, with a class of cases developing as a result of the changes accompanying or following the climacteric.

The term melancholia, employed in its broadest sense, applies to any state of depression occurring with primary dementia, general paralysis of the insane, hysterical insanity, the period of depression which obtains as a phase of alternating or circular insanity, etc.

The term melancholia of involution as understood from the present standpoint, can be applied to two groups of cases, which are characterized by the development of depression, with ideas of fear, delusions of self-accusation, of persecution, and ideas of a hypochondriacal nature, with moderate clouding of consciousness, and disturbance of the train of thought, leading, in the greater number of cases, after a prolonged course, to moderate mental enfeeblement.

Among women, the importance of the mental and nervous changes at the time of the climacteric, are apt to be underestimated. As unstable brains are likely, in certain instances, to be deranged in their mental operations by the slow development of puberty and adolescence, they are accordingly liable to suffer as those most impor

Read at the Semi-Annual Meeting of the Seneca County Medical Association, Cayuga Lake, September 8, 1904.

N. Y. STATE JOUR. OF MEDICINE.

tant powers of the organism diminish and disappear at the climacteric.

At the climacteric or involution period, there is unquestionably a mental change of peculiarly marked significance in both sexes. There may be a period of increased activity in sexual tendencies, followed by an invariable decrease of these tendencies, and ultimate diminution and extinction of the natural sexual activity and power.

There are changes of form, expecially in women. The expression of the face changes, the ovaries become atrophied, and the spleen and lymphatic glands become less active. The ordinary sensory nervous sensations, that are connected with the climacteric in women, such as vertigo, vaso-motor disturbances, flashes of light, uneasy organic sensations, headache, etc., usually occur before the menopause, rather than accompany it.

The time when the reproductive activities cease is usually reckoned as a period when there is special liability to mental breakdown, and climacteric mental disturbances in women, therefore, have a place in nearly all our etiologic classifications of mental diseases. The change has, however, more of the characteristics of a physiologic crisis than the development of puberty and adolescence, and should, therefore, be less likely to be attended by the development of so serious a derangement as insanity.

Individuals having a perfectly normal development, ought not to show any disturbance at this period, but such as possess perfectly normal development and function, are rare, and consequently it occurs very frequently, in the readjustment of the physical functions, that there will be a disturbance of the mental operations, that in extreme cases, or in those already predisposed, extends to actual mental disease.

Probably it would be difficult here, as in the cases of insanity of adolescence, to point out a definite series of symptoms characteristic of the mental derangement, that are so constant and recognizable as to constitute a well-defined spe

cies; but we can show a reasonable series of symptoms.

This form of melancholia, developing in the male, does not occur so frequently, relatively, as in women. It rarely develops before 50, usually occurs between 45 and 65. This period of life is supposed to occur, popularly, at the age of 63, just as in the female, the corresponding age is 45, as an average date. There is lessening of activity, spontaneity and courage, aggressiveness and poetic sentiment. There is less keenness of feeling in diverse directions; less delight in former acquaintances; sleep is apt to be less sound, Where the and hours of sleep are shortened. morbid tendencies are prolonged, and deep in impress, symptoms of a character similar to those obtaining in the regular involution cases develop.

ETIOLOGY.

The consensus of opinion among recent writers is that the disease should be regarded as one of

the evidences of approaching senility. The greater number of cases occur between the ages of 40 and 60. It seldom occurs under 40, or over 60. Sixty-five per cent. of the cases occur in women, when it may develop several years after the occurrence of the menopause; in men the onset is later.

Defective heredity can be ascribed as a predisposing cause in a little over half of the cases. Outside causes, such as the loss of friends, mental shock and worry, prostration accompanying or following acute or chronic diseases, surgical operations, exhausting physical labors, all can be located as definite exciting causes.

The only anatomical changes thus far located are those of arterio-sclerosis. The fibro-capillary changes are usually not very marked, being merely the beginning of that process. Direct observation of a considerable number of cases in Willard, reveals evidences of beginning or moderately advanced atheroma, in about half of the whole number of cases.

SYMPTOMS.

The first group of cases may be said to contain the greater number, representing those developing less severe indications of mental disturbances. The premonitory indications are often present for many months. The most common and persistent are headaches, often accompanied by soreness of the scalp at vertex, and heat or boring sensations in that locality. Vertigo, occurring as a regular symptom, when the patient is up and about during the day, or when reclining, or sometimes at night. Loss of appetite, anemia, general debility, constipation, cardiac palpation, and increasing difficulty in accomplishing work, are among the prominent symptoms.

The onset of the actual attack is apt to be gradual, sometimes extending through months, or even years. The patient, who has shown all, or part of the prodromal symptoms enumerated above, may become sad, dejected, and apprehensive, and unable to any longer find enjoyment or interest in her usual occupation, or home surroundings. This condition may be followed by the development of ideas of doubt, fear, indecision and self-accusation. The patients cannot reason correctly, and give little attention to consolation or advice of friends. Sensations of illness develop; they complain of absentmindedness, confusion, of being dumb and helpless, and find it difficult to do anything. During this period the patient may have occasional days when the apprehension, depression and anxiety disappear. Hypochondriacal ideas assume considerable prominence in many cases. They are, afflicted with various physical diseases, the nerves and brain are decayed on account of sexual abuse; they have no appetite, food tastes badly, contains poisonous substances, does not nourish, causes great suffering. Often these cases, plead that they be allowed to exist without food. Others may express ideas of having consumption and various other diseases. Ideas of bodily changes

often develop in these patients, as an exaggeration of the marked hypochondriacal trend. One may protest volubly and repeatedly that the throat and esophagus are closed up, that the stomach and intestines, or, in fact, all the abdominal organs are diseased, atrophied, or destroyed. Some claim that food, even when liquid and given in small quantities, causes great distress, and wail about sensations of distention, extreme pain, and sensation as though the stomach, intestines or other organs are bursting.

Constipation is another theme upon which the patient harps, persisting that nothing has passed the bowels in weeks or months, that remedies cause indescribable suffering, that the rectum has been closed for weeks, etc.

Sooner or later, delusions of self-accusation develop as a prominent feature of the picture. The patient becomes retrospective and introspective, reverting to comparatively insignificant errors, and magnifying them into serious misdeeds or positive crimes. One has corrected her child too severely, and now perceived that she had committed a great wrong. Another had neglected her son when he was ill, and now believed that she would never be forgiven. Still another had turned her children out into the inclement weather, and was constantly harassed by the idea that they were starving and freezing. Sometimes sexual indiscretions, either real or imaginary, are magnified into crimes of appalling importance, which condemn the victim irrevocably to everlasting torment. Some become so thoroughly imbued with the hopelessness of their condition that they invent crimes in their imaginations, in order that severer punishment may be secured, as a relief for their guilty consciences.

Religious concepts and delusions occur with many cases, either as a regular attitude, or as an occasional interruption. They have committed the unpardonable sin, cannot pray, cannot do anything right. God does not hear, or answer prayer. The Lord is punishing them through the miseries of others.

Orientation may remain clear, but is apt to be clouded and uncertain for location and dates, in some cases. On account of the strenuous desire to be free, and the knowledge that they are detained, patients in hospitals frequently develop the idea of imprisonment, or punishment on account of imaginary crimes. count of imaginary crimes. Usually, however, they have very fair comprehension of surroundings and circumstances, and consciousness is reasonably clear.

There is usually a degree of insight into the actual condition, the patients realizing that there is something wrong with their brains, but are unable to recognize the symptoms present, as evidence of disease.

The power of thinking is often impaired, quite coherent, and may be relevant to the subject, but the speech production and ideas are apt to be centered around the delusions. There is often a

tendency to repeat phrases connected with dominant ideas, such as "Let me go away. Oh! let me get out in the yard. Let me return to my children!"

Most of the cases show agitation, many distress and incapacity for employment. Some may be inactive, indolent, showing a certain amount of constraint in movements. The countenance is usually expressive of sadness; sometimes indicative of suffering. The voice is apt to be highpitched, strained and monotonous, especially in the agitated cases.

The inclination to suicide is especially prominent in these cases. There may be suicidal impulses without any previous warning, but usually the tendency to suicide is a matter of deliberation and opportunity, and, unfortunately, too many cases terminate by self-destruction, especially among those who are cared for at home during such attacks. This aspect of the matter has been brought forcibly to my notice within the past few days, in the case of a woman who was under treatment in the hospital. She had made four distinct suicidal attempts prior to her admission to the hospital, where she was committed and remained several months. At the urgent and repeated solicitation of her relatives she was discharged to their care about six weeks ago, after very careful arrangements for her care and safety had been agreed to by her relatives, as she was feeble and hopeless, and greatly distressed because of homesickness. Despite precautions which we presume were taken by her people, she managed to commit suicide a few days ago.

Hallucinations of sight and hearing often accompany this condition, but they are usually transitory and indefinite, not exerting any controlling influence.

The more severe form of the disease, includes a larger number of the cases usually seen in a hospital for the insane, and is distinguished by greater prominence of the hallucinations of sight and hearing, delusions of fear, often of a silly character, greater clouding of the intellect, particularly of consciousness, and severe agitation.

The premonitory and early symptoms are usually similar to those of the first group, and, as a matter of fact, some cases, after passing through a phase with symptoms corresponding to those already described, pass on to a condition of more severe disturbance, representing this second group. At the onset, the characteristic case develops more rapidly, especially if the exciting causes be prominent. The comparatively slight melancholia of the initial stage quickly passes into an extreme despondency. The patients develop ideas of extreme wickedness, have committed horrible crimes and desecrations; they plead to be put to death or tortured in the most atrocious and unnatural ways. Every speech or action of those about the patient is interpreted to have an unfriendly, sinister or diabolical motive. Inanimate objects noticed by the patient assume

mysterious importance and meaning, as the observation that a spoon is there for the purpose of giving poison. The hypochondriacal delusions grow extravagant and absurd. The brain is a mass of molten lead, a cake of ice; the blood has all dried up, or become congealed; the lungs have decayed; the body is putrefying; worms infest the flesh, etc. Aural and visual hallucinations are active and vivid. The devil often torments them with visions of fire, of frightful murders, of future punishment awaiting the sufferer. Hallucinations of taste and smell often give rise to delusions of filthy and vile substances in the food. Hallucinations of general sensation are sometimes vivid and terrifying. For instance, one patient insists that a demon is located in the left side of her abdomen. He communicates with her by tapping, the signals being arranged something like the telegraphic code, and her actions are controlled in this way, by this malign spirit, who punishes her by distressing pains and tortures when she hesitates to act according to his bidding.

Sometimes what is termed the "delire de negation" obtains in these cases, when the patients claim that an end has come to everything, that nothing any longer exists, that they are floating in space and the world has disappeared.

These patients are usually confused, show considerable disorientation for time, place and persons, and are prone to repetition of phrases. Frequently, however, as in cases of delirium, the attention of the patient can be secured, and fairly coherent and sensible answers to questions can be obtained, on subjects not connected with delusions. They show marked, and sometimes extreme agitation, beating themselves, wringing their hands in agony, picking at the flesh, and pulling the hair. Impulses to suicide and attempts at self-mutilation are frequent and persistent, and these cases usually require very careful watching on the part of the nurses, to prevent the execution of suicidal designs and impulses.

As already stated, the emotional attitude is always one of depression, which is based upon fear of something that has occurred, or is about to happen, and consequent anxiety and distress, causing agitation and distraction.

PHYSICAL SYMPTOMS.

On account of the agitation, anxiety, distress and distraction. the result of delusions, of fear and apprehension of punishment, the appetite is poor, digestion is disordered, the tongue coated, with fetor of breath often, and constipation obtains. Consequently, the patients become emaciated and reduced physically, usually in proportion to the severity of the mental disturbance. Many cases refuse food obstinately on account of delusions. Obstinate insomnia usually obtains, and some of the patients are harassed by distressing dreams. ing dreams. Cyanosis and coldness of the extremities are often present, and sometimes edema, due to cardiac dilatation, or impaired circulation, due to atheroma of the blood vessels, is noticed.

The course of the disease is usually prolonged. The attack usually develops gradually, continues several months at an almost uniform condition, and the improvement and convalescence in recoverable cases usually slow. Remissions of short duration may occur, and exacerbations frequently occur as the result of special irritations, as the visits of friends, annoyance or fatigue. Curable cases rarely recover within a year, and the duration is usually two years or more.

PROGNOSIS.

A reference to the opinions expressed by various authors, as well as consideration of cases in my own experience, shows this to be an unfavorable form of mental disease, so far as prospects of recovery are concerned. Only about onethird of the cases recover. In the others moderate dementia occurs after a few years. A certain number become quiet, fairly comfortable and sufficiently well to get along in the care of relatives, but even in such cases the danger of suicide is sometimes present.

The prognosis is usually more favorable in those cases, occurring early in the involution period. Many of the cases become emaciated, exhausted, and die of acute physical diseases. They seem particularly liable to attack by tuberculosis. A few who become quiet and improve develop a paranoic condition, without insight or comprehension. They develop ideas of wealth, of being favored of God, of having power to heal disease, and develop a childish attitude generally.

TREATMENT.

Comparatively mild cases may be treated at home, satisfactorily. Indeed, many of the cases who develop symptoms of melancholia of mild type, are cared for in their homes, or at least outside of a hospital for the insane, under the direction of the family physician.

The most important feature of the treatment in the beginning is to place the patient in bed, amid quiet surroundings, away from persons, as well as objects who cause irritation. This class of cases do not react well to long journeys, sightseeing, or other distractions. Attention to correction of errors of digestion, a varied and abundant diet, tonics when indicated, and suitable remedies to relieve insomnia, are the principal indications.

Even with mild cases the danger of suicide must be guarded against.

More severe cases, with marked anxiety, depression, agitation, and pronounced suicidal tendencies, can be more safely treated in a hospital.

The "rest cure" gives the most satisfactory results in many cases, although some are so agitated and resistant that it is very difficult to keep them in bed. On account of the severe mental restlessness, these patients usually become, sooner or later, much emaciated, show marked edema and lowering of physical function generally. Consequently, the most nutritious diet is re

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Perhaps the most troublesome and distressing condition met with in these cases, is the persistent insomnia. For the relief of this trouble in milder cases hot drinks, of milk, tea, etc., or the hypnotics, such as trional, sulfonal, or paraldehyde, may be efficient, but in more severe cases more active measures will be necessary. For these cases full warm baths or prolonged hot baths, or wet packs, act very well in many cases. The hydro-therapeutic methods of inducing sleep have largely superseded the giving of narcotic sedatives in the wards of hospitals where advanced methods of treatment are applied.

In cases where the insomnia and agitation are very obstinate, more powerful hypnotics, such as chloral-hydrate, chloralamid in combination with the bromides, may be required temporarily. Alcohol frequently acts well as a hypnotic, especially in patients who have been agitated for some time, and are becoming exhausted. It may be given as whisky, wine or beer, in the amount required, in the individual case, to act as a narcotic and hypnotic. Sometimes two or three ounces of spiritus frumenti, with thirty or forty grains of sodii. brom., in sufficient water, will act favorably as a hypnotic in a patient who is extremely frenzied and distracted, when sleep cannot be obtained from any other means, except large doses of chloral-hydrate, or hyoscine-hydrobro

mate.

In some cases the agitation, psychic distress. and frenzied condition can be relieved by increasing doses of opium or morphia. Occasionally this remedy will have a beneficial effect in controlling and relieving a severe outbreak. The mental stress and pain is usually considerably relieved by the morphia. When this remedy is exhibited, it is especially necessary to control the tendency to obstinate constipation, by giving appropriate remedies.

Additional means of treatment are massage, which is especially applicable when patients are kept in bed, to supply the lack of regular exercise. Tonic baths are also beneficial, to improve capillary circulation, relieve vaso-motor disturbances, and thus improve nutrition. Sometimes patients suffering from this malady will improve

faster when given a moderate amount of exercise and diversion out of doors.

The influence of surroundings, and of the nurses who come in contact with the patient, also counts in this, as in other forms of insanity. Persuasion, substitution of thought, where any response can be obtained, gentleness, friendliness and encouragement are often of service in relieving the anxiety and distress, and in diverting the attention of the patient from delusions.

Visits from relatives are often injurious, during the severer part of the disease, and may cause a serious relapse, even after improvement has been effected.

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DISEASES OF THE RESPIRATORY TRACT.

First, that a person suffering with obstructive intranasal disease-chronic nasopharyngeal catarrh is not laboring under a mere inconvenience, but has a malady that involves very serious danger, a danger that increases as years advance, and that, uncured, is a constant menace to the integrity of the lower respiratory tract.

Second, the neuroses dependent upon nasal obstruction are often as serious in their symptomatology, as they are distressing to the patient. They affect not only the respiratory tract, but the heart and other organs, often masking the real disease to an extent that may embarrass the examiner in making a differential diagnosis.

Third, that chronic catarrhal bronchitis is a disease of potential importance, slow in its progress, often depending upon nasal obstruction as a primary factor of cause, and is of most serious import in the aged.

Fourth, that asthma is, for the most part, a reflex manifestation of nasopharyngeal disease, generally obstructive in character; that it is seldom idiopathic, but its paroxysms are similar whether it be true or false, whether it be reflex or bronchial; and that its chief importance is as a symptom of disease located elsewhere, spasm of the bronchial tubes being a distressing expression of the lesion.

Fifth, that those diseases of the respiratory tract to which the veteran soldier is peculiarly liable, are often expressions of the rheumatic or gouty diathesis, and that these dyscrasiæ are often underlying factors to be reckoned with in reference to origin as logical sequences of pathology. As a final thought, permit me to suggest that it does not require much mental elasticity or any

distortion of facts, to affirm that a Civil War veteran suffering from chronic catarrhal disease of the respiratory tract, is as much entitled to rating and pension as though he were shot in battle. Such a man who, in childhood, received a slight injury to the nose, causing deformity of the septum, and in young manhood through exposure in the military service, contracted intranasal disease which later, after the development of rheumatism, appears as chronic rhinitis, bronchial catarrh, or pseudoasthma, is entitled to serious and considerate treatment at the hands of the Government.-Pensioner, October.

DEVIATIONS OF THE NASAL SEPTUM. In a review of 100 operations for the correction of deviated septa, by Dr. Joseph S. Gibb, published in the Journal of the American Medical Association, October 29, 1904, he offers some very practical remarks on septal operations:

septa are undertaken for the purpose of restorOperations for the correction of deviated ing lost or diminished function to the nasal

chamber. The disturbance of function is made

manifest to the patient by difficulty or impossibility of nasal respiration, necessitating mouth breathing, with all the ills this latter condition entails. Among the lesser, though by no means unimportant, effect of deviated septa there may be interference with excretory ducts, e. g., the nasal duct and the orifices of the accessory sinuses, and pressure neuroses. Any one of these conditions justifies an attempt to relieve by correction of the deviated septum. On the other hand, the correction of a deviated septum in a case in which there are no disturbing symptoms, is open to criticism.

Septal deviations, except in recent cases, are rarely sharply defined; we find associated with the septal irregularity thickening of the tissuescartilaginous, in those cases in which the cartilage alone is involved; bony, in those in which the bone is also deflected, so that we have in each case a septum pushed out of line, plus a redundancy of tissue composed of either cartilage or bone, depending on the portion of the septum involved. This redundancy of tissue is not confined to the nasal chamber toward which the septum is deflected-not infrequently the concavity is found filled with these thickened masses.

These, then, are the difficulties to be overcome in the operation for the correction of the trouble, and that operation will be most successful which overcomes these difficulties. It is of more importance to carefully study a case on these lines than to enter into an elaborate description of the character of a deviation as to its position in the nasal chamber. It matters little whether a deflection is along the horizontal or vertical axis or is sigmoid in its shape so long as we have a proper appreciation of the amount of deviation, and the concurrent thickening. Each case should be studied in itself and both nasal chambers should be thoroughly investigated, the extent of

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