OBSERVATIONS ON MELANCHOLIA.

BY DAVID A. GORTON, M. D.,

BROOKLYN, N. Y.

Among diseases classed as mental, none presents complications more numerous or appears under forms so varied as melancholia. The ancient physicians attributed the malady to disordered bile, hence the name they gave it, melancholia. Modern observers have extended the area of causes of this dread disease somewhat, without discrediting, however, the judgment of the Greeks, who found disorder of the hepatic function the cause in chief. In general, the phenomena presented by a person suffering from melancholia, even in its incipient stage, that of simple hypochondria, are bilious—that is to say, the general aspect of an individual so suffering is bilious. His physiognomy is clouded with gloom and misery. His skin is dry and yellowish; his form wasted. He suffers from dyspepsia. The tongue is loaded and the appetite wanting. The subject has wind and oppillations, gastric heaviness and eructations with oppression of the hypochondrium. He is spiritless and wanting in vital heat. The pulse is sluggish. He does not rest well. His sleep is fitful and disturbed by bad dreams. Nightmare is of frequent occurrence. He is tormented by evil forebodings which take possession of him and from the shadow of which he finds escape impossible. The functions of organic life are all depressed in any form of melancholia and those of conscious life suffer accordingly. Such are the leading bodily symptoms, subjective and objective, of persons suffering from incipient melancholia, or hypochondria, as Griesenger characterizes it. But the psychical symptoms are more pronounced. Mentally, the subject is low spirited, sorrowfuldejected. He goes about with the air of one who has met with some grave calamity-as the wreck of his fortune, or the death of his dearest friend. He is unhappy and discouraged; disposed to look on the dark side and to brood over troubles for the most part imaginary. He is weary of life; is disinclined to exertion of any kind; takes little interest in anything except his ill-feelings, of which he is painfully conscious. He cannot pursue his business with his usual zest. He does

not care to read, to meet his friends, to go anywhere, or to see anyDody. He prefers solitude, and yet fears to be alone. His ideas are sluggish, and while his judgment may be sound and his reasoning logical, his feelings are morose, disconsolate and unhappy. The will is impaired in the simplest form of melancholia, as evidenced by the patient's indecision as to the things of the least importance, such as going to drive, calling on a friend, changing his linen, going to a concert, or a lecture, etc. He puts off-postpones-neglects, defers, everything for the want of that interest in life and things which is the natural inspiration of all endeavor.

sexes.

This condition of body and mind is frequently met with among both The subjects of it are not insane, exactly, certainly not insane enough to be sent to an asylum, but yet they are insane enough to be miserable and to make others miserable. The cause or causes of it are numerous. Moral causes often produce it, such as the loss of fortune or of loved ones; disappointment in love, business, or ambition, etc. The prominent causes of this state of things may be summarized as follows: 1st. Neglect of the laws of organic life;

2d. Neglect of the laws of psychical life; and

3d. Extra-human, or unavoidable causes, as ante-natal influences, age, sex, mal-environment, etc.

The first category of causes embraces errors of diet and habits of eating and drinking, the consequence of which is mal, or defective nutrition; neglect of personal sanitation, that is, of the bodily functions and environment; disregard of the necessity of pure air and water, and of sunlight; exposure to extremes of heat and cold; and to malarial causes; indifference to rest and sleep, etc. Under these malinfluences the powers of the unconscious sooner or later succumb to disease, or are broken down utterly and with them the powers of conscious, or psychical life.

The second category of causes embraces errors in the use of one's faculties disregarding the laws of the mental economy. These errors consist in the over-indulgence of the passions; cultivating an inordinate love of pleasure; indulging habits of idleness and dissipation; confining one's self too closely to business to the neglect of rest and recreation; persistent violations of the sense of duty (in sensitive temperaments); uncongenial companionship; compulsory devotion to an occupation or business to which one is unfitted by natural bent or talent; vexations and worries, harassing cares and anxieties consequent on failures and disappointments (in over-sensitive temperaments); over-taxing the mind; following through long courses a single

line of thought, or prosecuting an exclusive branch of study or business in which but a part of the mind is exercised, as in bookkeeping, gratifying a greed for gain, the profession of music, language, theology, etc. These and a thousand other similar causes tend to weaken and unbalance the mental faculties and to prevent or destroy their influence over the bodily life, thus rendering the subject of them a prey to morbid or deranged emotions.

Case I. A case illustrative of this phase of melancholia, or mental depression, caused by mental strain and prolonged indulgence of a single line of thought was that of a gentleman, past middle age, who was connected with a large manufacturing business, having charge of the finances, to which he had devoted himself unremittingly during a quarter of a century, to the neglect of the claims of either body or mind. At first he suffered from dyspepsia, having feelings of oppression at the epigastrium, as if a paving stone had lodged there, and constipation. Later he suffered from depression of spirit and was continually haunted with the sense of impending disaster. Naturally of a sombre disposition, this peculiarity grew upon him, accompanied with sleeplessness, pain in the occiput and a sensation of burning in the top and back of the head, and occasional attacks of vertigo. Finally, collapse came and he was compelled to withdraw from business.

We treated this case mainly with Ignatia, Phosphoric acid and Strychnia, singly, and in succession, and of various degress of dilution; advised retirement from business, rest, amusement and travel. He recovered in the course of two years under this course; but during all that time, while his judgment of men and things was sound and his reason clear, he could not look at a column of figures without an attack of vertigo and faintness!

Case II. Another similar case, though of less gravity and of temporary duration, came under our observation more recently. It was that of a writer who under the demands of his publisher, continually overtaxed himself, writing often under the influence of stimulants in order to complete his tasks. A mild form of melancholia finally supervened and he was persuaded to take a brief vacation, from which he returned apparently in worse condition than before. We give the symptoms of his case and the circumstances of his recovery in his own words:

66 * * * I acted upon your advice and took a stroll in the country; lived much out of doors, riding horse-back and driving when the weather permitted. The remedies which you gave me were faithfully taken, apparently without benefit. I returned to the city a few

days since, under pressure of work which must be done, more dead than alive. You can hardly imagine the wretchedness of my days and nights. I seemed to be enveloped in an atmosphere of gloom and my being fairly to drip with melancholy. My mind seemed empty of ideas. I could neither read nor write. Conversation was a bore. Horrible fancies possessed me at night and profound lethargy by day. I ate fairly well and suffered no dyspeptic anomalies. My bowels were obstinately constipated; urine scanty, with a mealy sediment; skin dry and hot (the weather being warm).

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"This, in brief, was my condition when I returned to my post at the urgent importunity of my printer. He was waiting for 'copy' which I had promised to produce. 'How can I ever write again,' thought I. But I must do it,' I said to myself. Impelled by the necessity of the situation I essayed my task, but at first to no purpose. Again and again I tried to write, succeeding only in composing detached sentences quite foreign to the purpose. I walked to and fro in my rooms by the hour, alternately imploring divine aid and damning my stupid brain! When I fancied I had an idea I went to my desk and wrote it down, then would rise and begin the struggle again for another. Not to weary you with too great prolixity, this process of writing-this fierce struggle against what I could not help feeling was my own stupid brain-went on day and night, with infrequent intermissions, for three days, toward the end of which I began to feel some degree of mastery over my mind. Strange to say this mastery came in this way: I began to feel a rumbling in my bowels. From being as still as night and as motionless as a stick in the mud, my bowels com. menced to be noisy and to show signs of animation. The rumbling increased a pace until it become a roar, and the roar a violent cannonade! These were followed presently with a quantity of cibal-like dejections and these again with copious normal stools. The victory was won. From that moment my mind was liberated from the thralldom of locked secretions, and I could write with the ease and freedom of former days. I have only to add that the normal condition of body and mind was at once restored."

The experience of this gentleman, who is a man of stable constitution, which means an indomitable will, is most significant as showing the influence of the will over the bodily functions. Further comment would be out of place in this connection.

Case III. Another case of hypochondria with monomania, of malarial origin, came under our care a few months since. It was that of a single lady, of middle age, who imagined that she had rheuma

tism, to combat which she must keep herself secluded from the air and avoid the touch of water. We were called to her early in July, 1887, during the heated term of that year. We found her sitting up to receive us in a room, the windows and doors of which were carefully closed. The heat outside was 96° in the shade; the heat inside was rather less, but the atmosphere of the room was most stifling, being close and charged with the fetor of the patient. Still further to protect herself from the fear of fresh air, the patient was dressed in underwear of thick flannel, several flannel petticoats, a heavy woolen wrapper, two woolen shawls, and over these was wrapped a thick comforter. In bed she kept on the woolen wraps, including drawers, beside being covered by a bountiful supply of flannel blankets.

The patient had been in this state of dread of air for several months. She imagined that cool air was the source of all her woes and that in heat was to be found the healing of them; and she implored me at the outset not to deprive her of her wraps, nor to subject her to the drafts of an open window. Of water she had an equal fear, and she had not had a bath in months!

The leading symptoms of this case were slight chilliness in the morning with muscular pains, and a slight rise of temperature in the afternoon, accompanied with perspiration. At night the patient was sleepless and oppressed with vagaries. At all times she was despondent and occupied with her morbid feelings.

The treatment of the case consisted of Arsenicum alb., the 2d decimal dilution; a daily sponge bath (tepid); the proper ventilation of her room and the gradual removal of her surplus wraps. This last was finally effected by impressing upon her mind the danger she incurred of injuring her skin by the excessive perspiration which the excess of covering induced. The prompt recovery which she made was no doubt largely aided by disabusing her mind of the idea that she had rheumatism, and the positive assurance we gave her that she needed the out-door air and sunshine in order to get well. Hope is the most important element of therapeia in all these cases, to inspire which is to establish convalescence.

The hypochondriac is often suicidal. This is not due so much to disgust of life from which he suffers as to a characteristic impulse. While one suicide would be horrified at the thought of a particular mode of self-destruction, as for example, hanging, another would prefer hanging; while still another would have a decided preference for suicide by cutting his throat. The more horrible the mode of selfdestruction the more tempting it is to many of these cases, which