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the regular and systematic use of opium, administered in from twenty to sixty minims of Squibb's deodorized tincture three times a day. It appears to partially anæsthetize the supersensitiveness of the brain, and thus relieves the mental pain. It probably also exercises an influence upon the vaso-motor system of nerves, and thus indirectly increases the circulation. Opium may be used for weeks in this way, thus greatly relieving the suffering of the patient without disturbing the organs of digestion. As recovery advances it may be gradually diminished and abandoned without future inconvenience to the patient and with little or no danger of establishing the opium habit in the system.
The systematic and regular administration of food is of the first importance in melancholia. The patient will declare that he has already taken too much food, that it only causes irritation in his stomach and bowels, etc., etc., to all of which no attention is to be paid. A large amount of farinaceous and easily digested food must be taken during each twenty-four hours. It is better to take it in divided doses, so as at no time to overload the stomach. The tendency is to lose flesh and become emaciated; the nerve-centres are imperfectly nourished and consequently have an insufficiency of energy; hence, when the patient once begins to increase in adipose tissue, it is a most favorable indication, and one looking toward recovery. When the digestion is not good, broths, soups, with milk and eggs, may be given with ale, together with fish and easily digested meats.
Artificial Feeding.–As patients affected with melancholia, more often than others, require to have food introduced into the system by artificial means, it may be appropriate to refer to the subject at this time. The refusal to take food may arise from different causes in different cases; in some, from the delusion that all food offered or provided for them is poisoned; in others, from the presence of hallucinations of hearing; they think voices are heard commanding them not to eat, and that serious results will follow if they do; others imagine that they perceive things in the food which render it unfit to eat. The refusal of food may also arise from indifference to life, and from the fact that patients experience no craving for it, etc.
It is important to ascertain, if possible, for what reason food is refused, especially in patients recently received in an institution, and if it be from a general suspicion of those immediately about them, it will be well not to insist at once upon the patient's eating. It will be better to gain the confidence of the patient and allow him to follow his own inclination in the matter for awhile. Food of a tempting character may be left in the room, and opportunity afforded to eat when there is no one about to observe. In some cases such a course will prove best; suspicions will be allayed and a sufficient quantity will be used.
In other cases it will be necessary to introduce food to the stomach against the wish and earnest protest of the patient. This is usually done in one of two methodsthat is, by either a strong though flexible gutta-percha tube introduced through the mouth to the stomach, or by a soft and very flexible rubber tube introduced to the stomach through one of the nostrils. In some persons the muscular tissue and the soft parts immediately about the fauces are very sensitive to the presence of any unusual foreign substance, especially if it is hard. The stomach tube may, therefore, cause very strong contractions of these parts, and it will generally be better to use the nasal tube in such cases. Indeed, I have, for many years, been in the habit of using it in nearly all cases, as it appears to occasion less annoyance. It also avoids the necessity of using force to open the jaws by means of some kind of wedge or lever, as these are generally held very firmly together. There, however, exists, probably, a little more danger of the nasal tube passing into the larynx from the posterior nares than of the large and less flexible tube usually used for passing through the mouth; but, with requisite care, this very rarely happens, and the use of the nasal passage produces less irritation in most cases.
The food intended to be introduced into the stomach,which may consist of beef tea, beef extract, milk, or milk and eggs, with such medicines and stimulants as may be desirable, should be placed in a bottle designed for the purpose and made ready for use before the introduction of the tube. This being in readiness, and the tube being introduced, its free end should be pressed over a small nozzle which protrudes from one side of the bottle very near its lower margin. The bottle is then raised, and the contents at once pass into the stomach. This method is much more easy of execution, and more satisfactory in my experience, than the use of a pump and a stomach tube.
In some cases the irritation caused by the presence of the tube at or near the cardiac orifice of the stomach causes emesis, and what has been introduced is immediately rejected. In other cases the stomach does not digest the food introduced, and after a longer or a shorter period it is vomited. Under such circumstances the system may be supported for days, and even weeks, by the use of nutrient enemata, introduced to the rectum every four or five hours. I recall instances in which the life of the patient has undoubtedly been saved by this means. also be better for some persons who are very sensitively
It may organized and easily frightened; also in cases of females during the first few days after admission to the asylum, as the enemata may be administered by the attendant or the supervisor.
The importance of avoiding a too long delay in resorting to some method of artificial feeding when food has been refused can hardly be overstated. In nearly all such cases the patient has taken a scanty amount of food for a long time before it has been utterly refused.
Dr. Todd, the first superintendent of the Retreat, was accustomed to use iron very freely in the treatment of melancholia. He compounded a special preparation, and it has since been known as Todd's Mixture. I have failed to derive much benefit from its use, or that of preparation of the drug in this form of disease, and now rarely use it. On the contrary, I use strychnine, hypophosphites, arsenic, and, I believe, often with benefit.
It is important to bear in mind that melancholia, as a symptom, may be present in other forms of mental disease, for instance, in epilepsy, general paresis, senile insanity, and in one of the stages of folie circulaire. This symptom being the most prominent one in the form of insanity described above, properly determines its nomenclature.
No Invariable Standard of Mental Activity— The Frequent Changes in the
Physical System-Epochs of Life-Inhibitory Centres First AffectedDelirium-Definition—Ætiology-Profound Moral Impressions—Instability of Brain Structure— Mode of Invasion-Preceded by Feelings of Lassitude and Depression-In some Cases, however, the Disorder Announces Itself by Marked Excitement-Physical Symptoms-Contrast Between those of Mania and Melancholia—The Physiognomy - Pupils— Increase of Motor Activity— Tongue-Physical Strength-Anæsthesia-Insensible to Fatigue— Increased Flow of Blood to the Brain— Increase of Appetite-Excitement of Sexual Centres-Catamenia-InsomniaSensorial Derangements – Hyperästhesia — Hallucinations—Illusions, Mental Symptoms-Memory Quickened-Rapidity of Speech --Conduct is Mainly Impulsive, or of an Instinctive Nature-Element in ThoughtChange in Character as Evinced in Conduct of Business and in HomeLife-- Importance of Knowing the Full History of such Cases in Forming a Diagnosis-Convalescence.
As the term melancholia has been used from time immemorial as a synonym for sadness, dullness, and diminished mental activity, so, in like manner, has mania been used as a synonym for continued hilarity, excitement, and increased mental function in any special direction. Both depression and excitement may, and often do, cxist without any morbid basis and while the brain is in a condition of health. There can be no unvarying standard of activity in mental operations. Every individual may be said to be, in this respect, a law unto himself and limited by the constitution of his central nervous system. A degree and a