A case of melancholia; sudden illness and death

patient's mental state still precluded informed consent and SoPEG was implemented under Section 62 as a life-saving procedure. The patient started enteral feeding under the guidance of the hospital dietitian. The combination of ECT and PEG feedingresultedin a marked improvementin her physical and mentalcondition. Shewasdischargedwith the tube in situ, the district nurse being educated in how to manage the tube, with CPN and psychiatric review. It was decided that the tube would be removed when she attained a certain target weight of 47 kg, and she achieved this in ten weeks. She is now well at six-month follow-up with no depressive ideas and weighs 49kg.

Feeding via PEG is increasingly used in the UK for feeding patients after stroke and severe head injury. It has occasionally been used for patients with de mentia and depression (Bussone et a!, 1992). It is a simple technique with a 95% success rate for inser tion, procedure times of 15â€"30minutes, excellent tolerance by the patients (who are often at high risk from surgical procedure), low morbidity (about 6â€" 16%), and with a low procedure rate related to mor tality (0â€"1%) (Ponsky eta!, 1985;Larson eta!, 1987). The tubes are concealed beneath the patient's cloth ing and are therefore cosmetically acceptable and less likely to interfere with rehabilitation. This can be used as a safe and effective method for providing long-term enteral nutrition in patients with eating disorders as an adjuvant to definitive psychiatric treatment maintaining effective nutrition while psychiatric recovery takes place.
We believe PEG feeding should be considered for patients with treatable depressive disorders compli cated by cachexia as a safe alternative to nasogastric and intravenous feeding. BUSS0NE, M., LALO, M., PIErm, F., et al(1992)  sensations. He was, however, sleepless and he had dyspepsia, as was shown by a furred tongue and by very occasional vomiting, the latter being at least once induced by his putting his finger down his throat. Under treatment he at first rapidly improved mentally and gained in bodily weight; he attended and enjoyed the weekly dances, played lively airs upon his violin and seemed a most promising case. Unfortunately a relapse occurred. Not satisfied with two medical visits a day, he used to send letters to me as well. On Feb. 11th, 1890, he wrote: â€oe¿ I endure unsufferable agony; I fear to perish in this terrible state; I entreat you to examine my stomach and bowels.â€• At that time he had gained twenty-one pounds in weight since admission; he slept fairly, his appetite was good, his dyspepsia was better and he was doing garden work, but he had a craving to be examined, he had a constant wish to take purgatives and other medicines, and he even asked for operative treatment.
On Feb. 14th I was hastily summoned to him. After having had a good breakfast he had been seized with violent abdominal pain, and when seen he was kneeling in a bent position on a chair moaning and crying out with the severity of the pain. He was extremely restless and greatly agitated. There was considerable collapse, the pulse being thready and only 40 per minute, a cold perspiration covered his skin and the extremities were livid and cold. The pain was greatest over the epigastric region, but a proper examination was impossible as the muscles were rigid and the patient was quite doubled up as well as being very restless. Under treatment he improved considerably, so that, taking into consideration his great tendency to exaggerate, a hopeful view was taken of the case. By 2p.m. the pain was much less; the pulse, though weak, was 80 per minute; the tem perature was 97.4Â°F; and although he was exhausted his general condition, on the whole, seemed improv ing. During the night he again became restless, was weaker, looked very anaemic and had a fainting fit. In the morning he began to vomit and this con tinued till his death, which took place in the evening. The vomited matter was chiefly clotted milk, brandy and a little bilious mucus, but it was never stercora ceous. Early in the afternoon he was seen in consul tation with Dr. Burn-Murdoch. He had rapidly become worse; the pulse was not to be felt at the wrists, the expression was anxious and deathly pale, the vomiting continued, the respiration was deep and sighing, and generally he was exceedingly weak.
The pain was now most severe over the lower part of the abdomen. Normal faeces came away when an enema was given. He died at 8.10 p.m., thirty-five hours after the onset of the acute symptoms. The diagnosis was perforation with intra-peritoneal haemorrhage.
At the post-mortem examination, performed by Remarks. This case once more emphasises the fact that delusions, especially those relating to the viscera, often have real bodily causes for their foundation. The theory may be advanced that the intestines had always, or at least for some time, moved backwards and forwards through the con genital slit. The discomfort and uneasy feelings thus produced, acting upon a hereditarily weak brain, had induced the mental illness. Lastly came strangulation and death.