Cases of Heart Disease with Melancholia
162 Art. XV.? :Author : Geoege n. Savege, M.D. Tiie subjoined cases are reported with Dr Rhys Williams’ per- mission.
One is constantly struck by the many so-called compli- cations met with in insane cases.
In some, these complications have no connection with the mental symptoms. And in considering the pathology of insanity we cannot be too careful in excluding such affections. Many forms of mental disease are not fatal in themselves, and the patients have to die of diseases common both to sane and insane. Recently we have had two cases of ovarian dropsy, in which there was no traceable relationship between the ovarian disease and the insanity: one patient was acutely maniacal, and the other as profoundly melancholy. Another patient had a very large uterine fibroid, which in no way affected either her general or mental health. On the other hand, in many cases the state of the general health directly affects the mental state ; at times giving origin to the patient’s delusions, at others relieving altogether the mental symptoms. Chronic diseases more commonly have the former effect, and acute ones, such as erysipelas, the latter. In phthisis we often have delusions that the food is being poisoned, and partial dementia is not un- common after rheumatic fever.
We have had lately several cases of organic disease of the heart, and in all these the symptoms were more or less marked melancholy. The late Dr Thompson Dickson stated that such occurrence of heart disease in depressed cases was common. I have not found this to be the case ; but all, or nearly all the insane cases with heart disease have been melancholy. I have taken the pulse tracings of nearly every patient in Bethlem Hospital during four years, and have but rarely been led to suspect organic disease of the heart. In many cases ausculta- tion has also been used. I have not found more than 3 per cent, of heart disease in my cases of melancholia.
Again, on the post mortem table I have rarely found valvular disease of the heart. Fatty degeneration and atheroma of vessels and aorta are not uncommon, nor are such conditions wanting in the bodies of the sane who have died at mature age.
I have not been able to satisfy myself as to the reason for melancholy occurring in heart disease.
We find feeble circulation present both in mania and melancholia. Irregular action of the heart, and thus irregular blood supply, may explain some cases. In others, the purifica- tion of the blood being interfered with may lead to the symp- toms. In some the predisposition to insanity was present, and the trouble of heart disease has set up insanity; but we see cases constantly in which other forms of physical derangement set up mania or illusional insanity.
Post mortem, we find in melancholia commonly oedema of the membranes and excess of subarachnoid fluid. There is still a large field open for the observation of physical illnesses in insane patients, and I trust by careful collection of sets of cases some light may be thrown on the causes of mental disease.
Aortic Insufficiency. Melancholia. Death. William B? single, aged 25, an ironmonger Maternal grandfather was insane. Also maternal uncle and aunt and mother at present in an asylum. When a child had a fever, followed hy chorea, and was known afterwards to have heart disease. Two years before admission was short of breath for the first time; this has continued. Gradually he became un- like himself, lost his energy, and became moody and dull. He fancied he heard voices in the nest room, e re use o lie in bed at night; attempted to get out of window and was restless. Wanted to send telegrams, which were all nonsense.
Masturbation was suspected. Sleepless. Appetite was ravenous On admission he was a thin, sallow man, restless, suspicious, and suffering from hallucinations of hearing. In three weeks he improved, became bright and industrious His pu se tracing showed a very forcible pulse stroke that suddenly collapsed. A month after his admission he became obstinate, stripped himself.
His altered mental state coincided with constipation; lie im- proved again for a short time, and then again became dull. A loud double murmur was heard over the aortic valves; great increase of heart’s dulness; the apex beat was low and to the left, and was voluminous and forcible. He gradually became more dull and melancholy, and his breathing impeded. Six weeks after admission his breathing became worse; he became unconscious, though he could be roused for a time. Mucous rales were general, his heart’s action tumultuous; he gradually sank, and died fifty-one days after admission. Post mortem, we found some wasting of posterior convolution with excess of sub- arachnoid fluid, brain fifty-four ounces. Both lungs congested. Pericardium adherent throughout. Aorta much dilated above the valves, so that fluid regurgitated freely; no distinct disease of the valves themselves. Liver sixty ounces, fatty.
Melancholia. Aortic Disease. Recovery. John G-. W., married, 57, a chemist. Has a brother who is imbecile. Never had rheumatic fever or chorea. Steady and industrious. Earliest symptoms, depression one month before admission. His business was not successful, and this worried him. He cut his throat a week after the first symptoms. Was removed to St. Thomas’s Hospital. He lost a great deal of blood, expressed no regret at the act, and said ” It must be done.” No hallucinations. Deaf of both ears. On admission he was solitary and wretched. Slept badly and took his food badly. Pulse collapsing, tracing showing forcible upstroke and sudden fall. Heart’s dulness enlarged. Double murmur at base, audible but less distinctly at apex. A short time after ad- mission a large carbuncle formed on his neck. No mental change. It was difficult to get at his real mental state, as he was so deaf, but he remained solitary and unoccupied; the heart’s action being irregular. Digitalis was given ; this relieved him and quieted the heart. Two months after admission he began steadily to improve, became cheerful and industrious. He was discharged on leave at the end of four months, and finally well at the end of five.
Mitral Disease. Melancholia. Death.
Sarah II., married, 47. Paternal aunt insane. Steady and industrious. First symptoms, depression ten months before admission. No history of rheumatic fever or chorea. The earliest symptoms passed off, but she was subject to returns of depression of short duration. Shortly before admission she fancied everything was going wrong, and constantly, wanted to go to church. She next became excited and violent, incoherent, and full of delusions, such as that everything near her was filthy. For a month the patient improved mentally, then dropsy began to develope; this progressed steadily, her ab- domen becoming large and tense, and her legs much swollen. Digitalis had no effect. Jaborandi also did nothing to reduce the swelling. The heart’s action was so irregular and tumul- tuous that it was difficult to be sure of the nature of the disease; there was a loud systolic murmur at apex, loudest over ensiform cartilage, and not distinct behind or under axilla; the jugular veins pulsated violently. The breathing became affected, and she died two months after admission. No post mortem allowed. It was interesting to remark the mental calm during the severe physical suffering : for days she was breathless and sleepless, but quite rational in every way.
Melancholia after Rheumatic Fever. Recovery. Louisa M. S., widow, 30, governess, no family taint of in- sanity. Lived abroad for some time; had a severe attack of rheumatic fever, which affected her heart. The exciting cause of her mental attack was shock at death of husband, f1 our months before admission became depressed, this depression steadily increased ; she thought herself the^ greatest of sinners, and had an irresistible impulse to commit suicide, fehe was sleepless and suffered from menorrhagia. There was a faint systolic murmur at apex ; the pulse soft and rapid, at times irregular. No shortness of breath. This patient was one of the most determined and cunning suicidal cases we had, and caused much trouble and anxiety. Nothing seemed to improve her. She was always lamenting her wickedness. After 18 months in the Hospital she improved so far as to be trusted at home, and after six months of leave, was discharged well. I have here given two cases of aortic disease, both melan- cholia, and two in which other valves were affected. In one we had adherent pericardium following chorea and probably rheumatic fever, and aortic insufficiency ; m another, distinct historv of rheumatic heart affection; in two ot lers no such history, but unmistakable symptoms: the only things in common being depression and valvular disease of the heart. Hereditary taint was r>resent in three cases.
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