Melancholia

Melancholia (from Greek melas - black and chole - bile), literally "black-bile," a name reflecting the primitive humoral theory of ancient Greek medicine, which explained the gloomy, oppressive-hopeless mood of melancholics as poisoning of the body by black bile. M. represents a complex symptom complex characterized by a depressed, gloomy mood, slowing of movements, and difficulty in thinking. This syndrome, also known under the general name of depression (see.), presents various degrees, of which only the more severe are designated as M. Neuro-somatic symptoms of M. consist of digestive disorders (constipation), sensations of constriction in the chest and a peculiar heaviness in the heart region (precordial anxiety), insomnia and loss of body weight. Until the beginning of the 20th century, M. was considered as an independent acute disease of the affective sphere, admitting a favorable prognosis in 70-80% of cases; in addition, a transition to a chronic state, outcome in dementia, and recovery with defect were described. According to the content of delusional ideas, several varieties of M. were described: religious, hypochondriacal, resonating, with obsessive ideas, etc. According to the course, acute, recurrent, periodic forms were distinguished. All these subdivisions have now lost their significance, since M., or depression, is now considered as a symptom complex occurring in many mental diseases [primarily in manic-depressive psychosis (see.), in schizophrenia (Lange's psychogenic depression)], obsessive states, organic psychoses, progressive paralysis, etc. The longest independent nosological significance was retained for "presenile, or involutional melancholia," but even here at present the depressive symptom complex is considered only as an expression of the corresponding constitution (most often cycloid), which accordingly colors the picture of the psychosis, rather than as a pathogenetic factor: the cause of the disease in involutional psychoses is the involution of the body, experiences, while the external picture depends on the constitution and can be expressed in depressive, as well as catatonic, hysterical and other symptoms (see Involutional psychoses). It should be noted here that during involution, depressive states are usually colored by anxiety (Angstmelancholie). Lsh..-Lange J., Die endogenen u. reaktiven Ge-mutserkrankungen u. die manisch-depressive Konstitution (Ilndb. d. Geisteskxankheiten, hrsg. v. O. Bumke, B. VI, T. 2, p. 71, B., 1928).

10. Cannabich. MELAENA (from Greek melas - black), melena, "Hippocrates' black disease", "intestinal apoplexy", was known in antiquity and received its name from the black color of bloody stools and vomit. At present, this name is preserved mainly in the pathology of newborns and denotes a known symptom complex, namely - the excretion of blood through the intestine and stomach. The etiology of this phenomenon is not provided for by the name, it can be diverse and is far from being fully studied. - M. occurs relatively rarely: 1 time in 500-1,000 births; it was first described by Mauriceau (1682). It is usually divided into true (M. vera), in which the source of bleeding lies in the gastrointestinal tract of the child, and false (M. spuria), in which the source of bleeding lies outside it. The child may swallow blood from cracks in the breast, as well as during childbirth from the maternal genital passages, especially with deep or, conversely, marginal attachment of the placenta, with its early detachment, with ruptures of varicose veins of the vagina, with ruptures or incisions of the perineum, etc. Finally, blood can also come from the child itself with ulcers of the oral cavity (Zhukovsky), with hemorrhagic pneumonias, with fractures of the skull. In the latter cases, the amount of blood can really be large, while when swallowed from cracks or during childbirth, they remain mostly insignificant. Most authors accept the subdivision of true M. into 2 subgroups: M. symptomatic, when bleeding is one of the symptoms of another, mostly infectious disease (sepsis, syphilis, acute enterocolitis, intussusception), and M. idiopathic, giving a picture of isolated gastrointestinal bleeding; the prognosis of the latter form is usually more favorable. In recent years, Reuss and Rhenter, on the basis of the clinical picture, divide M. into 1) a late form, usually septic, beginning at the end of the 1st week, and 2) an early form, usually idiopathic, beginning from the 2nd-5th day of life, giving a better prognosis. Raisz gives a somewhat more complex classification and distinguishes a hidden form (M. occulta), which he found in 64% of healthy newborns when examining their stools for blood. There is no single etiology for M. vera, and many etiological factors have been proposed. The importance of ulcers found on autopsy in the stomach and duodenum, rarely in the esophagus (Henoch) and small intestines is emphasized. However, they are found far from in all cases: Baisch found only 1 time in 14 cases, Zhukovsky not once; the latter, on the contrary, observed the presence of ulcers without M. Therefore, the etiological significance of ulcers cannot be considered established. Landau explained their formation by the fact that emboli detach from the thrombus of the umbilical vein, which, being retained in the small vessels of the gastrointestinal tract, cause necrosis of the area supplied by the occluded artery. Other authors believe that due to the sharp hyperemia of the gastrointestinal tract during childbirth, hemorrhages occur in its mucosa, which can ulcerate under the influence of the corrosive action of gastric juice (peptic ulcers). Epstein emphasized the importance of asphyxia and reproduced ulcers experimentally in guinea pigs, in whom he caused respiratory arrest. However, it should be noted the great rarity of M. compared to the often occurring asphyxia in newborns. Pomorski and Preuschen see the cause of bleeding and erosions of the gastrointestinal tract in lesions of the central nervous system and also experimentally confirm the possibility of such ischemic ulcers. If no ulcers are found, then general hyperemia of the intestine, especially with prolonged labor, with a narrow pelvis, as well as stagnant hyperemia with congenital heart defects, especially with asphyxia, are proposed as the cause of M. - Another cause of M. is considered infection, and all sorts of microbes were found, mostly after death: strepto-, staphylo-, pneumococci, bacillus coli, typhoid and paratyphoid. Gartner singled out a special kind of "bacillus of melena", the specificity of which, however, was not confirmed. It should be noted that many authors did not find any microorganisms and that post mortem findings raise serious objections. The gateway for infection is rarely the umbilical cord, most often the intestine, the wall of which is more permeable to bacteria in this early period of life. Infection must undoubtedly be recognized as one of the important causes of M., especially its late forms. The role of syphilis is indicated, although the latter is far from always encountered (in Zhukovsky 3:25), as well as the role of birth trauma, which is often noted (in Zhukovsky in 25 cases of M. - 3 breech presentations, 3 forceps and 2 asphyxias). - Finally, changes in the blood are considered one of the causes of M.: the so-called "temporary hemophilia", decreased clotting, often present in M. (according to Grob in 80% of cases of early M.), decrease in the amount of prothrombin, etc. Bauer studied the capillaries in M. and found that their walls are often permeable in the first days of life. One of the predisposing factors is undoubtedly that "readiness for bleeding" which is characteristic of newborns, since bleeding is never observed so often later in life. Pathological anatomy. As there is no single etiology, so there is no single patho-anatomical picture in M. Usually the intestine is found filled with blood clots, its walls sometimes pale and unchanged, sometimes, on the contrary, hyperemic, with petechiae and hemorrhages. Often (40-45%) erosions, small necroses and ulcers of the mucosa are found, most often in the duodenum and stomach, rarely in the esophagus and small intestines. Ulcers can be superficial and deeper, penetrating almost to the serous membrane; occasionally penetrating ulcers were found, on the bottom of which gaping vessels could be seen. Anemia of the skin, mucous membranes and internal organs is found. In the presence of septic, syphilitic or other infection, the characteristic changes and degenerations in the organs will be present. Symptoms and course. The disease rarely begins on the 1st day, most often on the 2nd-5th day, sometimes later - at the end of the 1st or on the 2nd week (M. symptomatic). It most often affects strong, well-fed children, usually flares up in what seems to be complete health and only rarely after some precursors in the form of vomiting and frequent stools. The main symptom is bleeding, and most often there is only bloody stool or bloody stool simultaneously with bloody vomiting, and much less often only bloody vomiting. Blood is mixed with meconium or with mixed stool in the form of dark brown masses, sometimes of actual large clots. Metahemoglobin and hematin formed from Hb give the excretions a black color and a tar-like appearance with a shiny lacquer sheen. A soiled diaper gives off the characteristic smell of decomposing blood, and around the soiled area on the diaper a typical bloody rim is clearly visible. Vomiting is brown or red depending on the location of the bleeding site. - The course varies depending on the severity of the case. Usually bleeding reaches its maximum at the end of the day, and if it is profuse, severe anemia occurs; the pallor of the skin and visible mucous membranes is sometimes extreme, the fontanelle sinks, the temperature, initially elevated, falls below normal, restlessness, sometimes convulsions, cooling, changes in pulse and breathing occur, and death occurs with signs of collapse. Other bleedings often join: under the skin, nasal, umbilical, vaginal, etc. In moderately severe forms, gradual improvement may occur, the stool becomes less frequent and contains less blood, and the patient recovers with signs of more or less prolonged anemia. Finally, cases with an extremely favorable course occur, where everything returns to normal after 1-2 bloody stools ("formes frustes"). - Diagnosis is made on the basis of the presence of blood in the stools and vomit of the child, and it is necessary to differentiate true M. from false M. It is not always possible to determine the cause of M., but in cases of the late form, sepsis, syphilis, hemorrhagic enterocolitis must always be considered, in which, however, the admixture of blood to the stool is not so significant. - The prognosis depends on the etiology of the given case and is serious, but by no means hopeless. With usual methods of treatment and care, about 50% recover on average, and timely use of hemotherapy significantly increases this percentage. Early forms, with bleeding only per anum, give a more favorable outcome, while the addition of bloody vomiting worsens the prognosis. If bleeding lasts for two days without weakening, the outcome is usually fatal. - Prevention, observation of the pregnant woman, rational and careful conduct of childbirth, of course, also play an important role here. The use of strict asepsis in relation to the child has significantly reduced the number of cases of M. on the basis of sepsis. The treatment aims 1) to stop blood loss and 2) if possible, to affect the cause of M.

All haemostatics were used in this struggle for the child's life; ferrous sulfate, Hydrastis canadensis, ergotin, adrenaline, and calcium chloride with adrenaline hardly give results in serious cases. The greatest success was achieved by subcutaneous or intramuscular administration of 10% Merkov's gelatin in an amount of 10-20 cm³ (repeatedly if bleeding continues), as a result of which the mortality rate decreased according to Neu to 13%, and according to Nohl even to 5.5%. Zhukovsky successfully used gastric and intestinal lavage with cold physiol. solution. At present, however, the best method is transfusion of homogeneous blood, from which many authors had excellent results in severely exsanguinated children; from 50 to 150 cm³ (according to Vignesio, not more than 20) of the mother's or father's citrated blood is very slowly injected into the child's longitudinal sinus or jugular vein. Vigne had only 2 deaths out of 10 almost hopeless cases of M. In moderately severe cases, intramuscular injection (buttocks, 25% thigh) of 10-20 cm³ repeated every 8-12 hours gives definitely good results. Finally, placental serum, normal horse serum, and diphtheria antitoxin can be used. As etiological treatment for melena, Marfan recommends conducting antisyphilitic treatment. Great importance is attached to care: absolute rest, ice on the abdomen, warmth for the child's legs. Feed cautiously (10 times in small portions) with expressed and cooled on ice mother's milk, and if necessary, administer small amounts of physiol. solution subcutaneously. French authors prefer absolute abstinence from food for 24-48 hours and administer only cold water by the teaspoon per os.