ON

PERIODICAL MELANCHOLIA.

BY

WILLIAM B. NEFTEL, M.D.

ON

Periodical Melancholia.BY

WILLIAM B. NEFTEL, M.D.

A Paper read before the New Yorh MedicalLibrary and Journal Association,

October 3Oth, 1874.

Reprinted from The Medical Eecoed of August 14, 1875.

NEW YORK.JOHN F. TROW & SON, PRINTERS AND BOOKBINDERS.

1875.

ON PERIODICAL MELANCHOLIA.

Among the many cases of intense psychical depres-sion which I have been observing of late, one particu-lar group presents certain characteristic phenomena ofgreat theoretical interest and practical importance.This variety of melancholia I designate by the name of“periodical melancholia, ” and give here, as an illustra-tion of it, the following case:

Mr. H., 48 years old. His father was affected withossification of the coronary arteries, and died duringan attack of angina pectoris, at the age of 78. Hismother, now 79 years old, is suffering from melancholia,the first attack of which she had in 1887, the secondin 1857, and since then remains melancholic, with onlyoccasional intervals of improvement. Of his threebrothers, one died suddenly in his 48th year, the othertwo and a sister are healthy, though all have a slighttendency to depression of mind.

The patient’s health was very good until 1845,whenduring four months he was dangerously ill with dys-entery, from which, however, he entirely recovered.Since 1850 he has had a great deal of pruritus ani,with a mucous discharge. In 1850 he entered thebanking business, and filled a position of responsi-bility, demanding his incessant attention, and a greatdeal of work. Having experienced much anxiety inhis affairs, he had in 1851 an attack of melancholiathat lasted two months, after recovery from which he

4

had, at different times, slight attacks until 1861, whenhe had a second, more severe. Since then he is alter-nately healthy during several, at the utmost, fivemonths, and is then affected with melancholia, the at-tacks lasting from four to eleven months. They comeon gradually, the patient feeling at first somewhat de-pressed in mind, as often happens with healthy personsin consequence of some unpleasant occurrence orphysical indisposition, though in this case the depres-sion is without any cause. It continues to increaseduring several days, until it becomes complete apathy,a perfect indifference to all surroundings, a want ofdecision, an entire loss of courage, with a dread ofsomething fearful and inevitable.

The patient is then unable to attend to his businessor any other occupation; he cannot even read, for histhoughts remain concentrated on his own distressedcondition, and as he says, there are no words to de-scribe the intensity of his suffering, that would at timesmake him prefer death to such a life. He is opeu tonone but the most gloomy impressions, and everydiversion in other moods agreeable—for instance, acomedy or any amusement —would during the attackproduce upon him quite a painful effect. Nothingremains for him but to lead a life of seclusion, to avoidsociety and all kinds of pleasant impressions, whichseem then only to aggravate his condition. His appe-tite is bad, the bowels constipated, the sleep insufficientand disturbed by frightful dreams; he feels quiteweak, and loses flesh. At the height of the attackhe often experiences a feeling of chilliness and shiver-ing, also a great deal of itching ; has boils and erup-tions all over the body, which is not the case duringthe intervals. At last his condition becomes unbear-able ; he passes an entirely sleepless night, and expectsthe worst results, when suddenly he finds himself re-

5

freshed and healthy, to use his expression, “ As if someobstruction had been suddenly removed.” He is thusrestored to his normal condition, in "which he remainsduring a few months, when a new attack is sure tofollow.

He has been treated by most eminent physicians andneuropathologists, but his affection has never been in-fluenced by the different methods of treatment. Dr.Edward H. Clarke, the distinguished physician ofBoston, kindly sent him to me, and Nov. sth, 1873, Isaw the patient for the first time, two months after anattack.

He is of middle size, very thin, anaemic, and flushingquite readily. The skin dry, atrophic, unelastic; thesubcutaneous veins dilated; the hair of the whiskersbroken and split at the ends, causing them to appearas if strewn with sand. The mucous membranes (ofthe mouth, conjunctiva) are pale, and the muscularsystem but little developed. There is no deformity ofthe ears or of the skull, which latter, on the contrary,is well developed. His appetite is good, with occa-sional dyspeptic symptoms; bowels somewhat costive,prolapsus ani, with slight mucous discharge from therectum. His sleep was always deficient, not morethan four or five hours in the twenty-four, sometimeseven less. Pulse 70, respiration 18, costo-abdomiual;temperature, 37° C. ; weight, 124 pounds.

He is very intelligent, and of excellent businesscapacities, and not at all hypochondric, but, on thecontrary, of a good and gay disposition, always fondof joking, and never thinks of his attacks until theyhave actually come on. His general health is good,and he has no disposition to catch cold, though he isnot strong, especially in the arms, and complains of acold feeling in the right foot, and itching on the innersurface of the thighs. His mode of living is very

6

regular; he is quite temperate, and entirely abstainsfrom sexual intercourse.

As all the different remedies which had been triedhave failed to benefit the patient, I resorted at once tothe galvanic treatment, and prescribed at the same timea tonic regime, warm baths, and cold douches, exercisein the open air, etc.

He had altogether thirteen galvanic treatments ofthe head and cervical sympathetic from November sthto 18th, and, besides, I treated the prolapsus with in-duced currents. Under this treatment the. patient’shealth greatly improved: he felt strong, and couldwalk long distances; his appetite and digestion be-came good, bowels regular, and the prolapsus verymuch diminished; he slept seven hours every night,which he had never done in previous intervals. Theanaemia disappeared, the pulse became fuller, and theveins less dilated; the skin moist; the hair assumed anatural appearance; he had no more itching, andgained flesh, weighing one hundred and twenty-ninepounds. He felt quite well, and returned to his home.I advised him to come occasionally to New York

and continue the galvanic treatment, in order to pre-vent, if possible, the recurrence of an attack. Butowing to the illness of his partner he had to devoteall his time to business affairs; and finding that hishealth continued to improve, and that he could sleepmore than seven hours, he thought he would postponea prolonged treatment until a more convenient mo-ment, and therefore had but four treatments in De-cember and two in February. His health remainedexcellent during seven months, from September toApril, the longest interval he had had since 1861 (theother intervals being from two to five months), whena new attack manifested itself, and the patient re-turned to my care. I used the same methods of treat-

7

ment as before (galvanization of the head, sympa-thetic, etc.), but produced no beneficial effect. I thentried the so-called central galvanization and generalfaradization, also galvanization of the cord, and allthe known electro-therapeutic methods, without theleast benefit. On the contrary, the patient grew con-stantly worse; he lost flesh, became anaemic, the sleepunrefreshing and insufficient, the appetite bad. Hisintellect, however, remained undisturbed; he perfectlywell understood that there was not the slightest mate-rial cause for his depression; but it seemed to himthat there existed somewhere an obstruction which, ifremoved, would at once completely liberate him fromhis intense suffering. He, moreover, felt that this ob-struction was not even touched by the treatment. Hecomplained chiefly of want of decision and energy,and entire loss of interest in everything; loss of cour-age and fear of something dreadful; distress in theprsecordial region; impossibility of having any butgloomy ideas; concentration of his whole mind uponhis distressed condition, with no power of directinghis thoughts to other subjects.

Having exhausted all the known electro-therapeuticmethods without avail, I advised the patient to go tothe country (to the residence of his brother in Vir-ginia), and try a healthful mode of living ; exercisein the open air on foot and on horseback, a nourishingdiet, etc. He remained there from April 33d to Sep-tember 15th without any change in his condition, andat my suggestion returned to New York for furthertreatment. During his absence I had the opportunityof observing similar cases, and had tried a new methodwhich had proved successful, and which I wasanxious to try also in his case. It consists chiefly inthe production by the polar method of a condition ofanelectrotonus in the cervical sympathetic.

8

Though his present attack lasted five months, itnevertheless differed in several respects advantageous-ly from all the previous ones. In the first place, theinterval betAveen the two last attacks was longer thanever, as it was of seven months’ duration. He had notlost so much flesh, and weighed one hundred andtwenty-five and one-half pounds, while during theformer attacks he would run down to one hundredand seventeen pounds. His appetite and strengthAvere less diminished; the boils, eruptions and itchingdid not at all return this time, nor did the hair assumethe peculiar aspect above described; in fact, all themorbid phenomena within the trophic sphere AAr ere lessmarked than before. He had less dyspepsia and in-somnia ; the bowels remained regular, while formerlythey always Avere costive ; the prolapsus has scarcelytroubled him, and perhaps even the depression ofmind, profound as it was, did not entirely reach thesame degree.

After the first galvanic treatment by the newmethod he slept Avell, and felt the next day a greatdeal better than he had done since the beginning ofthe attack, though perfectly conscious that it was notyet over. I repeated the same treatment the follow-ing days, and his condition continued to improvesteadily; he felt more interest in everything, he couldread, and even enjoy a theatricalrepresentation, Avhichhe could never do during former attacks. After sixdaily treatments, always followed by a prolonged andrefreshing night’s sleep, his normal condition wasentirely restored. I treated him five days longer, andhe left Ncav York in excellent health, and still con-tinues to improve. He has already gained flesh (onehundred and twenty-eight pounds), all his functionsare normal, has seven hours of sound sleep, he feelsstrong, and is in good spirits. He himself ascribes to

9the galvanic treatment his present delivery from theattack for the following reasons, in which I entirelyconcur: Never before had he an interval of sevenmonths. All the former attacks, of which there hadbeen so many within twenty-three years, had termi-nated suddenly after a sleepless night, during theirvery acme. This time, on the contrary, the attackended gradually and slowly, in the course of a week,during which he enjoyed sound and prolonged sleepat night. Moreover, the improvement commenced im-mediately after the first treatment by the new method,without the least change in his mode of living andwithout the administration of any other remedy.

The chief points of interest in the described caseare:

1. The periodicity of the attacks.Though repeated attacks of melancholia in the same

persons are not unusual, yet they are generally veryfew and very far apart, and if the patient does not en-tirely recover, he passes into a permanent state of mel-ancholia, or into some other form of insanity. In ourcase the attacks recurred yearly during a long periodof twenty-three years, and without leading to any sec-ondary affections. The periodical melancholia afford-ed me an invaluable opportunity for the study of aseparate attack in its relation to the healthy intervals,thus throwing some light upon the pathogeny of mel-ancholia in general.

2. Loss of flesh invariably accompanied the attacks,and an increase in weight always followed as soon asthey were over. There was not a single exception tothis rule, which, must therefore be in intimate connec-tion with the phenomena of melancholia. The pa-tient’s weight at the acme of the attack was 117, dur-ing the interval 129 to 182 pounds.

3. The attack always commences with a subacute

10

anaemia. The general anaemia continues during theentire attack, and disappears during the interval. Theskin, the mucous membranes are pale, the pulse about55, small and feeble ; the veins, on the contrary, dilatedand distendedwith blood. These phenomena are alsoquite constant and admit of no exception. The anosmia,therefore, together with the loss of flesh (weight), mustnecessarily constitute an essential element of the mel-ancholic attack, and I consider these facts of the ut-most importance as regards the etiology and treatmentof melancholia, as will be seen hereafter. As a corol-lary I may also mention the morbid alteration of nu-trition, as manifested by the boils, eruptions and itch-ing of the skin, the splitting of the hair, etc. At theheight of the attack all the secretions seem to be di-minished, though I had no opportunity of verifyingthis assumption by a quantitativeanalysis of urea, etc.,secreted during twenty-four hours.*

The conclusions I have arrived at from observingthe phenomena of periodical melancholia may be ap-plied also to the other varieties of melancholia, a shortsketch of which I give here.

The state of psychical depression, known as melan-cholia, is one of the elementary forms of mental dis-eases, and has been described by Pinel, Esquirol,Falret, Baillarger, Moreau, and a great number ofother writers. To Guislainf belongs the merit of hav-ing elucidated the fact that the great majority of allmental diseases begin with a melancholic stage, whileGriesinger \ treated this psychical affection (psychosis)in close relation to nervous diseases in general, and

* After this paper was already sent for publication, the patient had anewattack, which, however, differs favorably from, the previousattacks;he is able to read, he sleeps seven hours or more, his appetite anddigestion are good, and there are no morbid phenomena in the sphereof the trophic nerves,

f Guislain. Lemons orales. 11., p. 162.X Griesinger. Pathologic und Therapie der psych. Krankh. 2 Aufl.,

p. 213.

11

Krafft-Ebing * pointed out the analogies of melan-cholia and neuralgia. Indeed, melancholia can be con-sidered as a psychical pain, a neurosis, a psychicalneuralgia of the sensory centres in the cortical sub-stance of the brain, analogous to the neuralgias in thesensitive sphere of the cerebro-spinal axis. In neural-gias the irritability of the affected nervous apparatusis so much altered that the slightest external excita-tions, mechanical, atmospheric, etc., which would notbe felt in the healthy condition, cause great pain.Even those slight but continuous excitations whichdepend upon the processes of circulation and nutri-tion, and are therefore normal stimuli and quite im-perceptible in the healthy condition, become a constantsource of intense pain in neuralgia. The same is thecase with psychical hypersesthesia, called melancholia,with the only difference that in neuralgia the affectionis in the sensitive sphere, and manifests itself asbodilypain; in melancholia it is in the psychical sphere, andis felt as psychical pain and depression of spirit.

In the first case the pain is produced by externalstimuli, mechanical, atmospheric, etc.; in the second,by psychical perceptions, ideas. In both cases a sym-pathetic affection in the motor sphere is apt to follow.Thus the part affected by neuralgia is instinctivelykept immovable; in like manner the melancholic, af-fected by psychical pain, lacks power of will, energy,and courage. Again, the convulsivemovements whichsometimes accompany neuralgia have their analogy inthe psychomotor impulses for acts of destruction, sooften noticed in melancholics. Lastly, both condi-tions, neuralgia and melancholia, are sometimes com-bined in the same subject, and both are often causedby a hereditary disposition, the neuropathic constitu-tion.

* Krafft-Ebing. Die Melancholic, Eine klinisclie Studie. Erlangen,1874, p. 3.

12We have to distinguish two classes of melancholic

affections, melancholia without delirium and melan-cholia associated with insane ideas, delusions; thoughthere are intermediate forms, and the first can passinto the other. Characteristic of melancholia is theimpossibility for the psychical organ to produce anybut unpleasant sensations; in other words, it respondswith painful emotions to everyimpression, even to suchas otherwise would be quite agreeable. As all the im-pressions from the outer world are felt in a most pain-ful manner, everything appears to the patient changedand gloomy, and becomes an infinite source of psychi-cal pain. “The painful perception of the outerworld,”says Kraftt-Ebing, * “manifests itself clinically in apassive manner; at the beginning the patient seeksretirement, avoids all association, andremains secluded;but afterward he becomes aggressive towards personsand things.” His relations to the surrounding worldhave now entirely changed ; he finds no pleasure inanything, nor can he be touched by the misfortunes ofothers, his own distress being much more intense thanall beside. Thus he lives in constant solitude and ap-prehension. In cases of melancholia without deliriumthe intellect remains intact; but as every psychicalact augments the psychical pain, the patient avoids alloccupation, becomes inert, undecisive, and broodingover his own sadness. He feels weak, his sleep is in-sufficient and unrefreshing; he has headache, palpi-tation of the heart, bad appetite, and constipation; heloses flesh and becomes anaemic. All the morbidsymptoms generally exacerbate in the morning, andwith female patients especially during menstruation,while toward evening a slight remission sometimestakes place.

If the melancholic condition is not relieved spon-* Loc. cit., p. 5.

13

taneously or by the efforts of art, or if it has not passedinto some form of insanity, the patient usually becomesconvinced that there is no remedy for his grief, and,driven to despair, he attempts, and often commits,suicide.

Like in every other nervous affection, so also inmelancholia, there are different degrees and varietiesof the disease.

numbers of persons affected with the milder formsof. melancholia are continually met with in life. Theymostly have a sad and morose countenance, an irrita-ble and changeable disposition, and are generally con-sideredwhimsical, and even malicious,until eventually,with the progress of the disease, after a lapse of years,a suicidal attempt in some of these cases will revealthe true nature of their affection. The great majorityof those who commit suicide are melancholics. Eventhe more developed stages of melancholia are notalways recognized, and such patients are sometimesconsidered as malades imaginaires or hypochondriacs.One patient of mine, a married lady, living in wealthand luxury, and sincerely attached to her husband andchildren, suffers for years with melancholia, associatedwith great distress in the precordial region. Her dis-ease is considered an imaginary one, as no materiallesion of any organ can be discovered, and she is gen-erally advised a change of air and travelling, whichinvariably aggravate her suffering.

Some of these melancholics, especially women, oftenresort to religious consolations, and are very apt toembrace a new faith, even at the sacrifice of the hap-piness of their dearest friends. One of these patientsconsulted me ; she had lately become a Roman Cath-olic, and says that she is now perfectly happy. Butit is easy to see that she is only theoretically happy,and that only the name of her affection has been

14

changed from a simple melancholia to a religiousmelancholia. She fervently devotes herself to her newreligious duties, goes to confession every morningbefore breakfast, spends hours in meditation, andleads an almost ascetic life. She has become muchemaciated, and is threatened with insanity.

A variety of melancholia very frequently met with,especially in men, is hypochondriasis. Here the de-pression comes from the fear of the patient for his ownhealth, which seems to him greatly imperilled. Thisstate of mind is often induced by some morbid peri-pheric impressions, caused by a slightly deranged ab-dominal viscus or any other organ, and these impres-sions the patient mistakes for dangerous symptomsthreatening his life. Hypochondriasis may also be ofa central origin, called forth by ideas, by reading medi-cal books or by association with other hypochondriacs.In one of my patients, a gentleman of superior intellectand culture, the hypochondriasis is induced by morbidsensations, originating in the sphere of a branch of thesciatic plexus (left nervus cutaneus femoris posterior).Though looking quite healthy, with all the organsin a perfectly normal condition (except some weak-ness in the sphere of the sexual organs), he was foryears a prey to great fear of paralysis, resulting, as heimagined, from some organic affection of the spinalcord, or of the kidneys, or of the heart, etc.

Melancholia is sometimes accompanied by an intensedistress in the precordial region, with palpitation andirregular action of the heart, epigastric pulsation, andother symptoms in the sphere of the vaso-motornerves—pallor and flushes of the face, cold extremities,contracted pulse, etc. These phenomena must be attri-buted to the cardiac plexus, and depend very proba-bly on a vaso-motor spasm of the cardiac arteries, asin some cases of angina pectoris. Attacks of pre-

15

cordial distress in a moderate degree happen, in myopinion, in every case of melancholia. In their high-est development (melancholia praacordialis) theseacute attacks, more than any other variety of melan-cholia, are apt to drive the patient to despair, to lossof mind, and to acts of destruction against things,persons, or his own life.

The melancholic state in its further developmentmay become associated with insane ideas, delusions,though occasionally it is so from the beginning. Wemostly find this variety of melancholia in cases withextreme precordial distress, and the slight forms ofmelancholic insanity are generally overlooked. Oneof my patients, a married lady, of a high moral char-acter, mother of several children, who suffers frommelancholy, with precordial distress, is convinced thather unhappy condition is caused by her husband, byincompatibility of their natures; and she is furtherconvinced that she would have been happy had shebeen married to any one else, or not married at all.And yet her husband is a highly respectable and hon-orable gentleman, of a beautiful external appearance,of an excellent character and kind disposition, verywealthy, and always ready to spare no expense tosatisfy every whim of his wife. She constantly leavesthe comforts of her luxurious home, and undertakeslong journeys to different places, her principal objectbeing separation from her husband. Her false theofyis shared even by her intimate friends, though inreality it is a purely insane idea —a symptom of pre-cordial melancholiawith which she is affected.

As the delusions originate from, and are constructedupon the most unpleasant sensations of the patienthimself, they must necessarily be of a painful nature.Thus, the intense precordial distress, which even in ahealthy person is associated with fear, dreadful appro-

16

hensions, etc., in the melancholic gives rise to delu-sions of danger, of persecution, and of death, embrac-ing every imaginable variety of human misery andsuffering.

A most frequent source of delusions in melancho-lics, are hallucinations, which, as may be easilyunderstood, occur sometimes in such nervous andexhausted persons. The patients hear voices an-nouncing their cruel fate; they see bad spirits, ormurderers threatening them; morbid gustatory sen-sations suggest the idea of being poisoned by enemies,etc. Such hallucinations are also the principal causeof the perverted and dangerous acts of melancholics.“Not unfrequently,” says Krafft-Ebing, * “is suicideor homicide their direct consequence, and a desperateact of self-defence against imaginary persecutors.Sometimes the decision to remain mute and refuse allnourishment is induced by a hallucination —a voiceprohibiting food and speech.” Melancholia, withdelusions, if not cured, ultimately passes into thepassive or active form. In the first variety (melancho-lia passiva, attonita) the indecision and loss of energyin the patient leads to a complete abolition of allvoluntary activity.

Those who have recovered from this affection de-scribe the feelings of terror and suffering they haveendured while in a state of obscured consciousnesssomewhat similar to a dream, and while unable to per-form the simplest act, having lost all voluntary power.They therefore remain motionless in bed or in a cor-ner, and finally scarcely react to external excitations.It seems as if there were an insurmountable resistanceto the psychomotor conduction. In the highest degreeof passive melancholia, the patients are in a state ofcatalepsy; the limbs are flexible as if of wax (flexi-

* Loc. cit., p. 37.

17bilitas cerea), and can remain indefinitelyin any given,even uncomfortable position, following only the lawof gravitation. There is a high degree of muscularand cutaneous anaesthesia and analgesia, and abolitionof reflex irritability; but the vegetative and automa-tic functions, though considerably weakened, still con-tinue. The eyes express anguish and awe. In thestate of passive melancholia the patients do not re-main longer than a few months. Sometimes they aresuddenly relieved from it as if awakened from a pro-found sleep; or theypass into some secondary form ofinsanity, or die during the acme of the disease fromparalysis of the nervous centres.

In direct opposition to the passive melancholia isthe active variety (melancholia activa, agitans). Thepatient affected by active melancholia instinctivelytries, and sometimes succeeds, to relieve his psychicalpain and distress by muscular activity, by constantagitation and locomotion. It seems as if the patient,at the height of his suffering, and by enormous efforts,succeeds at last in overcoming the resistance in thepsychomotor sphere, at least for a while. During sucha paroxysm of agitation, he runs about in despair, try-ing to destroy everything, his consciousness beingpartially or totally obscured.

The active melancholia, if not relieved in a shorttime, leads to death by exhaustion, or else passes intoincurable dementia.

At the autopsy of melancholics we find no materiallesions of the brain and its membranes, which exhibitan anaemic condition.

I now pass to the consideration of the practical partof the subject, the causes and treatment of melancholia.

As in all nervous affections, the most importantfactor in the production of melancholia is a certaindisposition, the inherited neuropathic constitution, and

18

in its highest development known as degenerescence,and described by Morel, Moreau and Legrand duSaulle.* It is progressive in succeeding generations,and this fact, perhaps, explains the increasing tendencyto and severity of nervous affections at the presenttime. The degenerescence manifests itself in differentways—by deformity of the skull, of the ears, theteeth, asymmetry of the face, etc., congenital club-foot and various congenital convulsive and neuralgicaffections. Very often there are morbid alterations inthe structure or functions of the sexual organs, untilin the later generations sterility or impotence put anend to the degenerescent families. Those sufferingfrom degenerescence are often eccentric, and amongthem the so-called inventors are largely represented.The most trifling causes are generally sufficient to in-duce the severest nervous diseases, and one of theircharacteristic features is the periodicity of their ner-vous affections. In persons of a neuropathic consti-tution, melancholic affections are easily developedunder favorable conditions, called exciting causes,which weaken the nervous system in general, and im-pair the nutrition of the brain. Thus constant mentalanxiety, depressing emotions, especially if long con-tinued and associated with insufficient sleep, irregu-larity in the function of digestion, with sexual andother excesses. In a number of cases I could trace theorigin of melancholia in females to the debilitating in-fluence of diseases incidental to pregnancy and thepuerperal state, mostly in those who have suffered fromexcessive vomiting during pregnancy, and from wantof sleep in nursing the child after confinement. Tothese circumstances I ascribe the fact that melancholiais oftener met with in women than in men.

According to my observations, melancholia is more* Legrand du Saulle. La folie hereditaire. Paris, 1878.

19

prevalent in this country than in Europe, and this Iascribe to the early application to business by men,together with want of sleep and irregularities in thedigestive and sexual functions.

From the study of the attacks in periodic melancholia,I have every reason to believe that the direct cause ofmelancholia is anaemia of the brain, perhaps only ofsome part of its cortical substance, induced by a vaso-motor spasm. This assumption is corroborated by thefact that the melancholic attack is accompanied byother phenomena in the vaso-motor sphere—the con-tracted pulse, the pallor and flushing of the face, thecold extremities, and especially the precordial distress,which latter in the form of angina pectoris, Landoisand Nothnagel have shown to be sometimes a purevaso-motor neurosis following a general spasmodiccontraction of the arteries. The alteration of nutri-tion, the loss of flesh, and the other symptoms ofmelancholia, are the consequences of cerebral andgeneral arterial anaemia, as I have had the opportunityof observing in the case of periodic melancholia. Ofcourse it is notprobable that a spasm should last duringthe wholemelancholic attack, but judgingby analogy ofother spasmodic affections, the spasms may follow eachother in more or less rapid succession, while their effect,which is the nutritive alteration of the brain, may con-tinue during the intervals between the spasms. Byadmitting this theory, which is based on facts, thephenomena of melancholia can be satisfactorily ex-plained, and the treatment becomes more rational andsuccessful.

The treatment must first be directed against theneuropathic constitution in order to prevent the de-velopment of melancholia, and then against the dis-ease itself. As regards the first, I arrived at resultsthat differ from the generally adopted opinion. Those

20

who are affected with an inherited neuropathic disposi-tion are, as a rule, advised to avoid intellectual occu-pations ; children are not allowed to study much, andgrown persons are desired not to devote their time toscience, art, etc. They have only to exercise their mus-cular system, to travel, to sport, and lead otherwise aquiet, idle, almost stupid life. Admitting the necessityof muscular exercise, I maintain that the intellectualexercise of the brain is stillmore important, not only forthe healthy, but also for the neuropathic individuals.That idiots do not live long is an established fact; butit is perhaps less known that even the physically strong-est persons, the athletes, if not intellectually developed,seldom, if ever, reach an advanced age, and that theoldest persons in any country are generally also themost intelligent. From the history of a number ofmy own patients affected with grave nervous andpsychical diseases it is evident, beyond any doubt, thatintellectual training or exercise of the brain is of theutmost value for the neuropathic persons. Thus a pa-tient of mine whose father died of softening of thebrain, who inherited degenerescence in the highestdegree, and who has been affected with the worstkind of epilepsy since his youth, is now living in hisseventh decade, having preserved all his intellectualfaculties. He is s charming poet, a writer of greatmerit, a student of mathematics and political economy,and possesses a profound knowledge of the literatureof different languages. His epileptic attacks werequite alarming; nevertheless, he followed his studies inthe universities, and continues them now, often passingwhole nights in abstruse mental occupations. Theolder he grew the milder and less frequent became theattacks; his memory is still good, and he still remainstalented and brilliant.

Another patient of mine with inherited degener-

21escence had his first severe attack of depression wheneight years old. He became in his manhood a con-firmed melancholic, and once made a suicidal attemptby cutting his throat with a razor. In spite of theadvice of his friends and physicians, in his later yearshe took up the study of the physiology and pathologyoi*the brain and of psychology, and though now aboutsixty years of age he is comparatively healthy and suf-fers no more of melancholia.

It is extremely important for persons disposed tomelancholia to avoid associating, and especially living,with melancholics. I have had patients who wouldprobably have escaped this affection had they not comeinto frequent contactwith melancholics. A robust andpreviously healthy person became melancholic afterhaving lived several years as maid to a lady thus af-fected, and strange to say both complain of the samemorbid symptoms. A young gentleman, the only sonof a melancholic mother, and who has never been sepa-rated from her, suffers exactly in the same wTay, thoughotherwise not resembling his mother. A young lady,daughter of a patient of mine, living in a boarding-school in another city, is generally of a cheerful dis-position, but becomes attacked with melancholia when-ever her mother makes a long visit to that city, and ittakes some time for the young girl to recover after thedeparture of the mother.

On the contrary, association with gay and humorouspeople, and healthy amusements, are very beneficialfor persons of a neuropathic constitution. The effectof laughing and of comic impressions has some im-portant physiological and psychological significance,as pointed out by Hecker.*

As regards the treatment of the disease itself it is*Hecker. Die Physiologie nnd Pathologie des Lachens und des

Komischen. Berlin, 1873.

22

necessary to bear in mind that the psychical organ inthis state is unable to produce any but painful sensa-tions, and therefore all kinds of excitation, all im-pressions, even pleasant ones, have to be avoided, andthe patient must be advised to keep quiet bodily andmentally. A few days’ rest in bed is sometimes themost beneficial remedy. Exercise, travelling, admo-nition, and religious consolations only aggravate thepsychical hypersesthesia. On the contrary, everythingthat produces relaxation of the vaso-motor spasm, andcongestion to the brain, acts beneficially. Thus pro-longed tepid baths and above all opiates, though onlypalliatives, often make life endurable, especially inthe variety of melancholiawith great precordial dis-tress.

Other remedies which act similarly may also betried, like inhalations of ether, chloroform, nitrite ofamyl, chloral, etc. I have not tried alcohol, whichalso produces congestion to the brain, on account ofits secondary injurious effects upon the system. Beingabsorbed by the blood, alcohol retards the oxidizingprocesses and the tissue metamorphosis, which seemalready weakened during the melancholic attack.

From my own experience I have every reason tobelieve that the most efficient remedy to abolish thevaso-motor spasm, to regulate the circulation of bloodin the brain, and to improve its nutrition, is the gal-vanic current, applied according to a certain method,the details of which will be given in a separate paper.

WILLIAM B. NEFTEL, M.D.16 East 48th St., New Yoek.