On The Treatment of Melancholia, or Lypemania
21 Art. II.?.
- Author:
Briebbe de Boisomont tie la Faculte de Paris, late President de la Societe
Jlcdico-Psychologique, &c.
The description I have given of tlie symptoms of tlie species of insanity called Melancholia, in another work, would lead to the belief that this form of disease is not very amenable to cure. That is, however, the opinion of the general public, of many physicians, and even of those who are devoted to the treatment of the insane, as to all forms of insanity. Looking at the power of hereditary predisposition, its transmission from generation to generation, the degenerative processes it induces, and the numerous relapses it exhibits, one might almost be inclined to admit the truth of this painful prognosis. But when any one has treated a great number of insane cases for a long series of years, he has the certainty impressed on his mind that many of these cases return to society, very often exhibiting, indeed, traces of their malady, but still capable of fulfilling the duties of their professions, and even of leaving their families in a good position.
As for myself, I find that in respect to mania, melancholia, and partial insanity, I have noticed numerous cures, or, at least, long remissions which are exceedingly like them. I met lately, after an interval of more than forty years, a former inmate of an asylum, whom I considered likely to remain there all his life. He had, however, quitted it for many years, and had married; he had also acquired an honourable competency, and reasoned very sensibly in reference to his malady. Again, I had been very intimate with a poet, whose connection with all the celebrities of the day rendered his friendship very valuable, and who furnished me with some important hints for acquiring a knowledge of the human heart. He had been treated in a private asylum, at a period still more distant than in the last case, for a hypochondriacal affection, which made him think he was every instant at the point of death. I had never lost sight of him until his death, which recently occurred. His reason was completely restored; and to hear him conversing with that variety of tone, that brilliant display of imagery, that delicate irony, and that charm of speech, which are found only in Frenchmen who are true Parisians, no one would have believed that he had been confined as a lunatic. Being aware of his former malady, he had determined to remain in the asylum.
Many classes of insane patients may then recover, but in order to avoid exaggeration, it is necessary to study carefully the different elements of this fortunate result. A certain number of melancholic cases recover once, twice, and thrice, some without having recourse to medical aid, and others by availing themselves of such assistance. Those who recover at home are especially those who preserve their senti- ments of affection, and do not feel any estrangement from their family, and do not manifest any dangerous tendency. I attended a young lady who fell from time to time into a state of extreme despondency, used to burst into tears, deplored her des- tiny, and said that death was a hundred times preferable to such a fate as hers. She shut herself up in her room, was always silent, scarcely ate anything, and slept very little; but in spite of this array of symptoms she never wished, under any pretext, to leave the asylum, where she at last ended her days. In most instances these patients, after several attacks which date from more or less distant periods, find their symptoms aggravated. The affections are perverted, and their relations and their homes inspire them with profound dislike. They are haunted by the most painful and terrifying insane ideas ; they have hallucinations and illusions of the same kind ; they have no desire for food, and they endeavour to destroy themselves. When they are taken in hand with these antecedents, some of them may still be cured. Most of them have long attacks, their faculties become altered more and more, and at last they become incurable.
At the commencement of the malady, when the family is in easy circumstances, and the patients are still able to under- stand their condition, recourse may be had to travelling, or to some intellectual, artistic, or physical employment; and not unfrequently success is achieved by the employment of these means, which are equally useful in the period of convalescence. But in the great majority of cases the serious nature of the symptoms necessitates the removal of the patients, afflicted with melancholia, to the asylums. I cannot overlook the facts that, out of 417 patients received in the space of 20 years?a period during which the observations were all made by myself, then intending to write a treatise the difficulties of which I fully recognised?80 of them refused their food, several of them died of exhaustion at the time of their arrival, 120 had continual apprehensions of death, 122 had made one or several attempts at self-destruction, and 7 succeeded in doing so in my establish- ment. It is truly necessary to have good sense and judgment to require, under such circumstances, before placing the patients in the asylum, a double or even triple medical certificate, an examination before a magistrate or a member of the Committee of Inspection, or even an enquiry by a jury, especially when, after having been present at numerous sittings of the Committees of Inquisitorial Examination of the law of the 30th of June 1838, I have heard the members of the magistracy who were present declare that they had never known, in the exercise of their functions, of any case of arbitrary detention of a patient. Only one of these gentlemen had entertained some doubts in reference to a patient whom he had examined ; but information, gained at the fountain head, enlightened him as well as myself as to the real nature of the mental disturbance and its cause. At the end of a terrible scene, the wife had revealed to the patient that she was the daughter of a convict, who had been exhibited and marked in a public square.
I shall now enter on the question of the treatment of melan cholic lunatics, and shall prefer to rely on facts observed by myself, without making them subservient to any preconceived idea.
Among the therapeutic agents which I have employed it- melancholia, prolonged baths, with or without irrigations, last- ing from one to two, three, four, or five hours, have proved beneficial in my hands when the malady was recent, with agitation, want of sleep, heat of skin, and refusal of food. If the patients are apathetic, motionless, silent, dumb, presenting symptoms of stupidity, unwilling to take any food, attempting suicide, passing their motions under them?then the half-warm bath, with cold affusions by sprinkling (en arrosoir), or in the form of the shower or the douche, is often beneficial. A lady, who had been always of a serious turn of mind, having been exposed to some insulting proposals, was so strongly affected by the circumstance that a marked change was effected in her whole deportment. She remained motionless and as if terrified. Being placed in a half-warm bath, she had several affusions of cold water in the form of shower (en jpluie), and on the eighteenth day she was cured.
Of the 198 patients who went out cured, namely, 163 com- pletely restored to reason, and 35 with all the indications of recovery, the greater part received great benefit from the baths, the duration of which was in proportion to the effects produced. I took notes of seventeen cases cured by this mode of treatment. One of them recovered his reason the third day, having had no previous attack. Nine others, similarly circumstanced, were convalescent at the end of a fortnight. The seven others who also went out cured in the first month presented peculiarities which, at their admission, might have justified a certain amount of reserve, or even a doubtful prognosis on the part of the physician. Thus, one presented symptoms of a melancholic affection which threatened a long duration; a second had alternations of improvement and relapse; a third, in progress of cure at the second bath, had heen afflicted for years; a fourth, threatening to kill others and himself, afterwards admitted that he had been ill, but declared that he was so no longer. The behaviour of this last caused the most serious apprehensions of suicide, but after fourteen days’ treatment a great improvement became apparent, and a visit from his relations materially accel- erated his convalescence. A fifth patient, who had already been afflicted for five years, had relapsed, and had serious paroxysms which inspired fears for his life: he refused to take any food. The sixth, whose relatives evinced a predisposition to insanity, had suffered, a year before, from typhoid fever, followed by mental derangement; he threatened to kill his mother, was dissatisfied with everything, and excited apprehensions for his life. To my astonishment, after a very brief delay, a change for the better took place. Lastly, the seventh, born of a maniacal mother, was a sufferer from nostalgia, and had become profoundly indifferent and apathetic; her appearance was, from time to time, that of a person in ecstasy ; her words were strange and her monologues interminable ; she heard none of the words which were addressed to her; but all of a sudden she appeared to wake, as if from a dream, and became convalescent. Facts such as these were alluded to by Dr Brown at the annual meeting of American alienist physicians, held in 1870, at Hartford; and our lamented colleague Bell, being asked as to the question of prognosis in insanity, replied: ” After having attended lunatic patients five years I thought I knew a great deal, but now that I have practised twenty years, I can affirm nothing certain scientifically.” There is, undoubtedly, some truth in this observation, but without asserting anything too boldly, we may approach very closely to the truth by founding our opinions on the results of experience.
It is often indispensable to use purgatives in addition to the baths, but the drugs must be disguised, because melancholic patients imagine that they are being poisoned. Tonics, chaly- beates, and quinine, are also of great service.
A powerful auxiliary in the treatment is family life (vie de famille). Ofuislain recommended melancholic patients to be isolated, and to rest in bed. The very frequent tendency to suicide by these patients in our country, and the turbulent character of the race, led me to adopt this plan more than thirty years ago, and I communicated it in 1866 to the French Insti- tute. M. Lentz, the medical Director of the Asylum of Froidmond, in Belgium, has pronounced a warm approval of my plan in his pamphlet, Des Causes de Vencombrement toujours croissant des Asiles d’alienes et des remedes a, y apporter (1871). He agrees with myself in thinking that it is woman who takes the most important part in the management of this system, in which the influence of the affections is a posi- tive good. A man’s character cannot bend itself to this kind of slavery. The trial is, in fact, one of the most painful character, since it is necessary to hear continually the same complaints, the same sorrows, and often the same reproaches and even insults. To the qualities of her mind and heart, woman joins the natural control which she exercises over man. The following were the terms in which I expressed my views to the Academie des Sciences: “The advantages of the family life, especially for melancholic patients, are too evident to require me to insist upon them at any length. Patients are brought to us who are indocile, dissatisfied with everything, agitated or apathetic, believing themselves to be surrounded by enemies, refusing to do anything that is asked of them, irrational in their acts, incessantly complaining, difficult to please, and even insupport- able to those around them, &c. A short time has scarcely elapsed since their admission before the social life in which they have entered softens their tempers, and they soon become friendly with their fellow-inmates. This is not indeed a cure, but it is already an improvement in their condition. Compare the spectacle you behold with that in which the compartments are separated, and where the sub-divisions are multiplied, I do not fear to say where the insane are penned (parques), and it is impossible for the most superficial observer not to notice imme- diately the difference of the two proceedings. The deduction is quite natural. Do you wish to restore to society patients whose isolation necessity has compelled? Show them, then, the favourable side of that society by fulfilling towards them the functions of consoler and friend, of physician both of mind and body.”
I related some striking examples in the memoir published in 1866, in the Annales Medico-Psychologiques, and since that time cases have been multiplied. I shall relate only one. An ecclesiastic had been confined five years in a very large asylum. Being transferred to us, he soon testified his satisfaction at the change. ” I was completely isolated,” he said, ” in my sub- division, and no friendly voice sounded in my ears. Since I came here, these ladies have addressed to me only words of con- solation, and I am most favourably impressed by them. I live in a totally different world.” In a short time he was cured. He left us at the end of the month, and was able to resume his duties, which he had never performed since his first confinement in the asylum. I have had news from him for several years, and he continues quite well.
The family life, the advantages of which are proved to me by long experience, is no more a panacea than the employment of prolonged baths and continued irrigations in the treatment of acute mania, but I consider this assemblage of patients under the intelligent direction of a woman as being far superior to the classification of the insane in compartments. Everything that resembles ordinary life in the management of mental diseases is preferable to any systems, however apparently well designed; and I have had sufficient proofs that the more the patients live in society the less unhappy they feel. Such is the remark made by Shakspeare in ” King Lear.” The family life, however, admits the painful measure of isolation in cases where such a step is necessary. This auxiliary to the general treat- ment is not only favourable to the cure of mental diseases, but it often retards, even for years, the progress towards the chronic stage. Lastly, its prompt application succeeds in several cases in weakening insensibly the insane ideas of the patients, and in developing among them some favourable manifestations which prove its influence.
The change of place, and the impression made by the asylum, must also be taken into account in reference to the cure. I have collected twelve cases in which some favourable results, due to these causes, have been immediately appreciable. Three of these patients, belonging to the female sex, were the victims of attacks of melancholia, and had been habitually depressed for one, two, and five years. In the first, whose attack of melancholia had been aggravated by the design of killing a person whom she named, the improvement was manifested on the very day of her admission, and it was well known to all of us what was the cause of her improvement. The second, who rapidly improved, began to be convalescent towards the fifteenth day. The third patient was the sister of a lunatic who had been placed in the house forty years before; she herself, who was always of a singular temper, would not see her daughter, who had been married five years, giving as her reason that she knew she was happy and that was enough for her. She had scarcely been admitted before the improvement appeared, and she became as kind to her daughter as she had formerly been. A patient who had been apathetic for two years used to lose every two days his freedom of mind. He answered hastily, and even sent away his clients. The two following days he experienced some difficulty at first in co-ordinating his ideas, but he soon resumed the direction of his business; an analogous condition to that which exists in persons in their senses, who have moments of disgust and apathy and cannot settle to any- thing. Being uneasy about his condition, he came to Paris of his own accord to place himself in my asylum. A favourable change was soon apparent, and he returned to his own home convalescent the second month after he came to live with me. These facts, and many others, prove to me the favourable effects of change of place, and of the influence of the asylum. The different methods I have described may each separately effect the cure, but their combination contributes more efficiently to that end. In addition to the physical and moral agents already indicated, which belong to general practice, there are others which are unforeseen and instantaneous, such as accident, or some word or idea or repartee, or some other circumstance, may bring into play, and which may produce the happiest effect.
A melancholic patient, tormented by hallucinations of hear- ing, which repeated to him incessantly what he ought to do, and at the same time prevented him from deciding upon it, was strongly urged by a person who had read my book on Hallucina- tions to confide himself to my care, assuring him (according to his opinion) that I should explain to him this morbid pheno- menon, and enable him to get rid of it. After having listened to him with great and profound attention, I looked at him with an appearance of satisfaction, and taking my cue from the feeling of certainty that his cure had been accomplished, I spoke to him with the air of a person who was so sure of having hit his mark, that I saw the appearance of hope in his coun- tenance. From the time of his interview there was a marked improvement, and he made such rapid progress that he left the establishment convalescent on the eighteenth day. A suitable observation or a ready reply is equally efficacious, at an opportune moment, in arresting the attention and chang- ing the course of the ideas. A lady complained of being- placed under restraint, declaring that oddities of character, however morbid they might be, are not a sufficient justification for such a step. In the bath she made an attempt at suicide, by endeavouring to drown herself. Being called immediately, I said to her, ” You asked me why you had been placed in con- finement ? It is acts such as these which explain the tendencv of the mind.’’ ” That is true,” she replied. The remark had gained its object. Reflection came to her aid, and the lady, having never thenceforth attempted any irrational act, went away convalescent in the course of the month. It remains to consider, however, the when and the how. Sometimes instinct is the best guide. We must, too, however much we mav be tempted, never allow ourselves to be carried away by the usage of the profession, but listen to the voice of pity up to the last moment.
Another melancholic patient, suffering from hernia, being- dismissed from all the establishments in consequence of his continual complaints, which were often unfounded, began the same course of conduct in my house. His arguments being of a nature to cause some trouble, I said to him, ” You may go away,” and I showed him the door; ” but yet,” said I, ” I should recommend you, in consequence of your hernia, to select an establishment where there is a skilful surgeon, for you are liable to serious risks.” I had at that time as assistant a retired surgeon-major, who was a very skilful operator. My advice excited the patient’s attention, and he determined to remain, and no longer once asked leave to depart.
This case recalls to my mind another, which is a striking- example of the value of a word spoken at the suitable moment. In the first establishment which I conducted there was a furious maniac, whom we could approach only when we were acccom- panied by a number of attendants. He thought that he was the great Napoleon, and was constantly irritated because he was not treated with the respect due to his rank. One day, when he was exceedingly violent, and wished to execute everybody because they did not prostrate themselves before such an illus- trious personage, my predecessor took it into his head to reply to him, “You are, it is true, Napoleon, but Napoleon is at St. Helena.” At that moment this furious madman ceased to revile and to strike, and he repeated several times, ” Napoleon at St. Helena,” and he afterwards became easy to manage.
Although the asylum is of great importance on account of the treatment and the discipline, and the society it promotes among the residents, yet there are several cases where the departure from it contributes to the restoration of the patients, or to their comfort, or may be indispensable for those objects. This plan may be limited or it may be complete, and its employ- ment depends on the knowledge we have of the insane, and on medical tact. I do not allude to chronic invalids, who may go out every day with an attendant, or occasionally take walks ‘ with the officers of the establishment, but only to particular cases.
Among the means of treatment which I have employed several times with success, anticipated leave of absence, the suitable time for which is learned by experience, ought never to be neglected, and the following case affords a proof in point. A music-master, after an attack of melancholia, became more tranquil, though still retaining some extravagant notions. His subsistence and that of his family depended on his business; and if his condition lasted some time longer, his position would be lost. I allowed him to go home. He had, however, some peculiarities. He began his lessons again, but returned to the asylum to dine and sleep. In two months he was quite well. I have had two officials attached to great public establish- ments, one of whom was able definitively to resume his duties after a year of surveillance, although still believing that he was in the power of the devil; and the other obtained his retirement in three years, although he had visions and insane ideas. The principals of the establishments in question, being very intel- ligent men, and appreciating the services rendered by their officials, consented to the course I have described, when I represented the case to them.
An attempt of this kind may be made under more serious circumstances, if there are some indications either of a returning” power of the will or of a commencing improvement. A mer- chant placed at the head of a great undertaking persuades himself that he has not sufficient capacity for such a position. An extreme degree of discouragement takes possession of his mind; he hears voices threatening him. He will not succeed, he will ruin his associates in the undertaking, he has nothing more to do than destroy himself. Three weeks pass without any appreciable change. One morning I saw him come in. ” I am,” he said to me, “still the same, but I cannot remain any longer, for my retreat will be discovered and everything will be over with me.” I hesitated, but I had a kind of intuitive notion that the patient had just taken a step towards improve- ment. I gave him his liberty. Two months afterwards he thanked me. No one had found out his condition; everything was prospering; the experiment had been successful. The pro- mised departure is sometimes a beneficial measure. A melancholic lady was improving; she admitted that she had been ill, but maintained that there was not sufficient reason for shutting her up with mad people. As I was afraid that with this frame of mind she would cause some unpleasantness with her husband and with the establishment, I advised her family to take her back. She was scarcely made acquainted with the fact that she had only a limited time to remain, when a remarkable improvement took place. She became gay, easy in her manners, made no more complaints, appeared to be pleased with us, and departed quite convalescent. When the acute stage is passed and the malady remains stationary, when there are no evil tendencies, and the patient wishes to return to his own home, and revisit his relatives, his’ wish ought to be granted. More than one melancholic patient 30 THE TREATMENT OF MELANCHOLIA, OR LYPEMANIA. lias been restored on finding himself in tlie midst of his family. I have had for a rather long time in my asylum a lady who appeared sunk in a kind of indifference from which nothing could divert her. I advised the husband to take her back with him. A few months afterwards, all the morbid symptoms had disappeared, and health was restored.
Visits of relations, which are justly regarded as dangerous in the acute stage of the disease, when it is still at its height, may, on the other hand, produce a marked improvement when the patients wish for them, and even in some cases when they occur unexpectedly. A young lady by chance caught a sight of her mother, who had come to ask after her. This patient, who was still in the period when her malady was increasing, experienced so much joy that convalescence soon ensued. A cure may take place without any treatment having been adopted, as I have already mentioned, and may even occur suddenly. One of our inmates, who had had an attack of melan- cholia seven years before, had a relapse of her malady. Six days after her admission she came to me, saying, ” I am cured, my visions are gone.” I was unable to refer this instantaneous improvement to any known cause.
The cure may also be due to unforeseen circumstances. A lady, who had sunk into a melancholic state from sorrow caused by losses of money, made several attempts at suicide, and obstinately refused to eat. Being admitted into the asylum, she gained the affection of an old patient, who succeeded in feeding her. She gave her advice, and told her the histories of other inmates, in order to prove to her’tliat their malady had attacked them because they had acted as she had done. By degrees she roused her up and made her smile. The insane ideas were removed, and the patient of our lunatic left us, repeatedly stating that to the latter she owed her restoration to reason.
Sometimes the passions serve as means of cure without the intervention of the physician. A man, about thirty years old, and rather reserved, having always lived a wandering life, was on the point of adopting a profession. When any discussions of importance were begun on this subject, he became irritated, ex- perienced severe pains in his head, and believed himself in the power of persecutors, who were laying snares for him, and accus- ing him of wicked actions ; he persuaded himself that he was dis- honoured, and he made attempts at suicide. The second month of his residence in the asylum he showed some attachment for a lady-friend of mine, and from that moment a sensible improve- ment was perceptible in his condition; he became more and more enamoured, and proposed marriage. The union was im- possible, but the cure was not interrupted. This unexpected diversion of his thoughts produced the most beneficial results on his habits and disposition. Nine years afterwards we again saw our old patient, who had married, had had children, managed his house well, and was not at all moved by the sight of his former flame.
In other cases, the predominant feeling which had acted alone is sometimes employed by the physician, and lends him some valuable assistance. A working builder, who had received a certain amount of education, was brought to the asylum on account of some eccentric proceedings. He would not speak, answered nobody, kept his head high, and his look was proud, disdainful, and ironical. By his appearance I recognised him to be a wrong-headed person, who supposed himself to be the victim of the injustice of society. I addressed him as a well- educated man; I conversed with him about his abilities, the rank to which he had a right, and his misfortunes, and I con- tinued talking with him in the same strain for some time. I perceived that I had touched the right chord ; he unlocked his teeth, spoke a few sensible words, and consented to eat, which he had not done for several days. The improvement continued. I often directed the conversation to the position he might occupy, diverting his mind as little as possible from his real condition in life, but pointing out to him what progress he might make in it. He listened to me always with interest, saw things no longer on the dark side, thought that he might make himself useful, and departed at the end of two months under circum- stances of health which led me to form a favourable opinion as to the complete return of his reason.
Nothing is absolute in the precepts of medicine. Although the length of time which has elapsed since the appearance of the disease is a contra-indication of success, it is not less certain that cures have been effected after several years of insanity. I have remarked three examples of this nature.
A very intelligent lady, who had managed for several years with remarkable ability a very complicated commercial under- taking, was seized with a fresh attack of melancholia similar to one she had suffered from thirty-six years before. She had re- mained five years in this state, keeping her bed for several months, when she saw a person belonging to my family going to the midnight mass at Christmas. ” Pray Grod for me,” said she to her. During her illness she had contracted the habit of thee and thouing (tutoyer) every one. On the return of the person alluded to from the mass, who came to ask after her health, she replied, ” I thank you ” (vous, not te) ” for having prayed for me.” This difference of language immediately made me think that her condition was about to change, and, in fact, from this time lier continual complaints were no longer heard. She left her bed and came into the drawing-room ; and in two months more she was quite well. She has visited us for several years without having felt any symptom of her malady.
A second case of melancholia, coming from another asylum, where she had already passed several months, was sent to me in an extreme degree of weakness. For more than a month she had been fed with the tube. I ceased this plan of feeding, and substituted for it the method I adopt in similar circum- stances, which consists in making a disagreeable impression on the patient, and which has almost always succeeded in my hands. On the second attempt she consented to take her food like the rest, and this was the only improvement I succeeded in obtaining. For a long time she urgently requested to be allowed to receive her husband and her son. A visit from the former had no successful result. It was thought that the sight of her son would be more efficacious, but I did not share this opinion, because she had visual illusions, which, indeed, were soon developed. She recognised neither of the two; took them for strangers, insulted them, and even wished to strike them, thus producing such a powerful emotion in the youth, that he burst into tears, and uttered loud cries. The experi- ment was not repeated. At the end of five years this lady was placed in a government asylum, from which she went out cured two years afterwards. It was she herself who announced to us her return to society, and the termination of her mental affection.
The third patient, whose attack was of ten years’ duration, had lost her reason in consequence of an indecent act on the part of her husband, which had compelled him to resign an important position, and to leave his native town and to come and take a business in Paris. Since the circumstance in ques- tion, domestic life had become a hell upon earth ; the husband had resisted as far as he could, for, as if she wished to be revenged on him, she related his story to every one who came. The distant date of the commencement of the malady made me look unfavourably on its probable termination, though hoping the case was not desperate, inasmuch as no intellectual weakness was discernible. In the first few months no change was manifest, but one day she spoke, for the first time, some kind words of her husband, and this was the announcement of an almost unhoped-for improvement. Her progress was rapid, and of her own accord she asked to return home to her husband.
Insanity, when joined with other affections, and more espe- cially those of a nervous kind, may neutralise them to its own advantage, or even disappear with them in a general cure. A patient who had suffered from a gastralgic affection for eight years, at last became emaciated, acquired a yellow tint, and could scarcely eat. Whether the attack of melancholia, which had lasted for some months, was the consequence of the former disease, or that it had been induced by the distressing nature of his condition, it made such progress that his friends were obliged to send him to the asylum. A short time after his admission he began to take food in greater quantity. Three months had scarcely elapsed before he had become stout, his face was of healthy colour, the jaundiced appearance was no longer visible, and the melancholia had disappeared at the same time. His health and his reason were restored. Another sufferer from gastralgia, who was habitually reserved and gloomy, exhibited a result exactly similar, thus offering a fresh example of the close relationship existing between nervous diseases and insanity. The affection, from which he had been suffering for years, prevented him from taking sufficient food, and he was visibly becoming emaciated. In consequence of the aggravation of the melancholic symptoms he was placed in the asylum, and he was soon observed to have an appetite, which was not previously known to exist; he rapidly gained flesh at the same time as the intelligence was becoming re- established, and he left us cured of both his maladies. Among the plans of treatment I have indicated, there are two which have not been mentioned. They have a relation to two classes of symptoms of extreme gravity, namely, the refusal of food and the tendency to suicide, both of which require special remedies.
The motives which induce melancholic patients to refuse food are very various. Ideas are detected which have no reference to such refusal; irresistible impulses; a feebleness of resolution ; and a complete forgetfulness of past events; but most generally there are hallucinations, illusions, gloomy ideas, an extreme disgust of life, and, above all, a feeling of despair in regard to their dreadful condition. It is inexpedient to be too hasty in having recourse to forcible alimentation, for some of these patients, after fasting several days, take their food; but others are satisfied, for a month or more, with a cup or two of broth or other liquid, even when they are robust and are great eaters. If the refusal of food is obstinate, and founded on an insane notion or hallucination, if the breath is fetid, if there is no febrile disturbance, then forcible alimentation is indispensable, and it must also be resorted to, even though the patient should consent to take food from time to time, but in small quantity; because very often, at the end of this prolonged insufficiency of food for several months, the patients have died and have wished to die.
The instrument most generally employed is the oesophageal tube, either simple or modified, of MM. Baillarger and Blanche. It is not uncommonly the case to be obliged to use it for rather a long time, as the patients become accustomed to the proceed- ing. Dr Zelarchi has related a curious case in which this plan was adopted during two years and fifty days. The silver mouth-piece of M. Billod is also useful.
Tbe facility with which a good number of insane patients allow themselves to be fed by these plans, the long continuance of the malady which. results from their adoption, and the chronic state which has seemed to me to follow their use, have induced me to practise, for more than thirty years, a method of treatment which is painful, indeed, but which, in my hands, has a different kind of efficiency from the oesophageal tube. The following is the plan I adopt. When the patients are brought in who have eaten nothing for several days, and are sometimes even exhausted by fasting, I warn them that I shall be under the painful necessity of subjecting them to a painful mode of treatment which will do them much harm. “My conscience,” I add, ” does not permit me to be present, as a mere witness, at the loss of a man who might be saved in spite of himself.” Some are intimidated, and yield for a time. The greater number resist, and we then put a strait-jacket on the patient, and fix him in an arm-chair, from which he cannot move, called a fauteuil de force, or lay him on his bed. We then introduce into one of the nasal fossae a tube armed with an iron rod, slightly curved at the lower end, and pass it as far as the back of the mouth, when the rod is withdrawn. I do not endeavour to pass the tube into the oesophagus, because that is not the object in view. An assistant closes the mouth with his hand or a napkin several times folded, another assistant applies his fingers on the nostril which is free, and we pour in the broth, tapioca, chocolate, &c. with the aid of a funnel, the end of which is introduced into the tube. An injecting syringe may also be used, the end of which is placed in the tube. The patient makes the greatest efforts not to swallow, but, in order to breathe, be is obliged to perform the act of deglutition. As soon as the syringe or the funnel is empty, we allow the patient to take breath for a few seconds, and then we begin again to pour in fluids. There is undoubtedly great struggling and embarrassment of breathing, but seldom any symptoms of commencing asphyxia. There is also almost always a certainty of speedy success, for the greater part of these patients yield at the first trial, and will seldom brave the second, especially if the physician has shown determination and refused to allow delay. Besides, the terror of the tube sometimes acts like a true moral revulsion, and the patients are not only cured of their instinctive perversion, but also of their insanity. A young girl refused to take any food because everything offered to her appeared in her eyes to be covered with sperm. Reasoning and other means employed had been unsuccessful. Forcible feeding cured her in two days. A young woman and an aged lady were brought to me this year (1872), who for several days had obstinately refused food. Their weakness was extreme, and there was even an apprehension that they would die. The aged lady was a fresh victim of the attacks of the newspapers, for, the family to which she belonged having divided interests, it had been necessary to hold a family council in order to come to a decision about sending her away, and to obviate unjust accusations as to shutting her up. After a few days’ residence in the asylum the cure was effected. Neither of them resisted more than twice the treatment just referred to, and the young lady went out cured in the second month. One of the most decisive examples was that of a paralytic lunatic, who kept his teeth so firmly clenched that it seemed easier to break them than to open his mouth. This patient thought that the devil had got possession of him. On the second introduction of the instrument, he took his food easily. His abstinence, which had lasted from five to six days, had given him the appearance of a person with organic disease; he exhaled a fetid odour, his lips and tongue were black ; but all these signs disappeared in three days, and from that time he again took his food. It was only necessary to show him the tube to make him obedient. This plan fails in a few rare instances, and requires great prudence, but, on the whole, it has been attended in my hands with beneficial and rapid results. Forcible alimentation is almost always unsuccessful in the febrile state.
The refusal of food may, sometimes, depend upon separation from the domestic circle. In two cases, in which this cause was clearly proved to me to exist, I sent away the patients to their homes, and this course was attended with success. In another case, after improvement for a few days, death supervened. It happens, on the other hand, that melancholic patients who would not take any food from the hands of their relatives, take it when they are sent to an asylum, and the apprehensions they have entertained then disappear. A young man from the provinces, who had abstained from every kind of food for five days, sat down to table as soon as he came to the asylum, and at the end of ten days he completely recovered.
A happy thought, as I have already observed, may be sufficient to overcome this obstinate refusal of food. A patient presenting symptoms of imbecility, and who had not spoken for three or four months, suddenly ceased to eat, and this abstinence was prolonged for six days. This case occurred at the beginning of my career, and the family, being alarmed, requested me to call in Esquirol in consultation. This distinguished physician prescribed some medicine, but especially recommended that the patient should be immediately taken into the country, in order to divert his ideas. It was six o’clock, and I had a few friends to dinner. We sat down at table, and I took it into my head to have the patient brought in. At the sight of more numerous dishes, and food more delicately prepared than usual, he smiled, took what was offered him, and ate with a good appetite. The crisis was over and did not re-appear. What is most surprising is, that this patient, whom we had believed to be imbecile, was restored to reason several years afterwards. The second very serious symptom of melancholic insanity is the tendency to suicide, with attempts to effect that object, and sometimes even with fatal results. It often manifests itself, for out of my 417 cases of melancholia, deducting 122 persons who had only gloomy thoughts of death, without attempting to meet it, I have noted 120 cases with attempts, and 7 with actual suicide.
The rather large proportion of those whom I have known to attempt self-destruction by plunging their heads into their baths; throwing themselves from the top of a tree or from a roof; stabbed in a few moments ; dashing themselves against a wall or against a pane of glass in their rooms ; succeeding in killing themselves even before our eyes, as happened to Guislain, or in the presence of a servant, and sometimes while the servant was asleep; and the rapidity with which these fatal intentions are carried into execution by the French?all these circumstances have made me resolve to employ coercive measures with patients whose suicidal tendency is obstinate, and accompanied with attempts in spite of our precautions. W’hen the idea of suicide is not stereotyped on the countenance, when the acts are not repeated, and when the patients pay some attention to what is passing around them, then, before employ- ing precautionary measures, we keep them under our own eyes, and this watchfulness on the part of the principals of the asylum, continued for a long time, often arrests in a remarkable degree their desire of death.
The strait-jacket and cuffs are the measures of repression which I most commonly employ. The language we adopt with the patients under these circumstances expresses the regret we feel at being driven to this sad extremity. We represent to them, in a tone of kindness, that the confidence reposed in us by the relatives, the distress caused by suicide, and the account we have to render to the authorities, compel us to act in this manner. When the eye of the patient has returned to its natural state, or has lost its fixed appearance and its sinister expression, and when the predominant idea has been weakened and no longer reveals itself, except at distant intervals, then we relax our precautions.
Some years ago I wrote to the effect that, in cases of this kind, the important point was to gain time and to make sure of the expression of the face. When the physician has devoted himself constantly to this study, he can read the mental condition of the insane patient as well as he can that of a man in his senses. A guide which singularly assists in this study is a knowledge of the previous life. In the employment of the measures alluded to, much tact is necessary as well as firmness and gentleness, and it is necessary also to discriminate the cases, and always to speak to the patients, according to the excellent advice of Daguin, in the language of reason, even when they do not appear to understand it.
It will be observed that I have but little increased the catalogue of medicines adapted to melancholia, although I have known relief afforded by the bromide of potassium and chloral (especially the latter), in procuring sleep, and such is the general result of experience. My opinion has been formed for a long time as to the preference which ought to be shown to simple modes of treatment. Baths, purgatives, hygienic measures, and moral treatment, especially the living in society (vie d& famille), constitute the methods I have adopted during a career of fifty years, and they are the means which have succeeded best in the treatment of melancholia.
As a general conclusion regarding the treatment of this mental malady, I may say that I have known it to be successful in a good proportion of cases. Although some patients recover in their own homes under medical treatment, or by unforeseen circumstances, the greater part of them owe their restoration to reason to the care bestowed upon them in the asylum; and what deserves notice is that the most numerous cures take place from the first to the third month, when the patients have been received in time.
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