Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

The more experience the specialist in mental diseases has, the less liable he is to give an opinion that will assure friends of the patient that relapses may not occur after any form of disturbed mentality. While this is true in mania, [{214}] it is almost more generally admitted with regard to melancholia. Most patients who have one attack of severe depression of spirits will surely have others if they are placed in circumstances that encourage the development of melancholic ideas. Any severe emotional strain will be followed by at least some symptoms of greater depression than would be expected from the normal person under the same conditions.

Professor Kraepelin has pointed out that in about one out of six cases the patients who came to him supposedly for the treatment of primary attacks of melancholia proved to be really suffering from a relapse of severe mental depression. The careful investigation of the history of these cases showed that they had suffered from previous attacks of depression, though sometimes these were so slight as not to have attracted any special attention from the medical attendant,—if indeed one had been called in the case—and at times even failed to occasion more than a passing remark on the part of friends with whom the patient was living.

The most frequent form of idiopathic insanity is melancholia. The disease is characterised by depression of spirits. Professor Berkley's definition, besides being scientifically exact, is popularly intelligible. According to him, "Melancholia is a simple, affective insanity in persons not necessarily burdened by neuropathic heredity, characterised by mental pain which is excessive, out of all adequate proportion to its cause, and accompanied by a more or less well-defined inhibition of the mental faculties." This latter part of the definition is extremely important. In extreme cases patients are able to accomplish no other mental acts beyond those which concern the supposed cause of their depression. Their lack of attention to other things is the measure of the mental disturbance. Their minds constantly revolve about one source of discouragement. They become absolutely introspective and their surroundings fail utterly, in pronounced cases, to produce any reaction in them. In milder cases this involves an increasing neglect of whatever occupation the patient may have, solely for the purpose of giving up time to the contemplation of the cause of his depression.

It is not easy always to recognise the limits between a [{215}] depression of spirits that is not entirely abnormal and a corresponding state of mind that is manifestly due to insanity. When misfortunes occur, individuals will be mentally depressed. Sorrow has in it necessarily no element of mental alienation. It is only when it becomes excessive that observers realise that there is disturbance of the mental faculties, causing the undue persistence and the exaggeration of the grief.

For example, a mother loses an only son in the prime of manhood and at the height of his career. It will not be surprising if, for a considerable period, she is unable to take up once more the thread of life where it was so rudely interrupted. For weeks she may react very little to her surroundings and may prove to be so moody as to arouse suspicion of her mental condition. After a time, however, she begins to have some of her old interest in affairs around her. Her depression of spirits may not entirely disappear for long years, perhaps never; but her affective state does not go beyond a simple sorrow. On the other hand, under the same circumstances, a mother may give way to transports of grief that after a while settle down into a persistent state of dejection. Every thought, every word, every motive, has a sorrowful aspect to her. After a time she may begin to think and even to state that the misfortune of the loss of her son has come because of her own exceeding wickedness. She may consider it a punishment from on high and think that she has committed the unpardonable sin and absolutely refuse any consolation in the matter. This state of mind is distinctly abnormal, and if it persists for some time must lead to the patient's being kept under careful surveillance.

The immediate cause of the development of such a melancholic state is always some unfortunate event in the course of life. Worry and sorrow are important causative factors. Mostly, however, these causes are only capable of producing their serious effects upon the mental state of predisposed individuals, or at times when the health of the subject is decidedly below the normal. Emotional disturbances are not liable to have such serious effects, except when anaemia, or continued dyspepsia, or some serious nutritive drain upon [{216}] the system, like frequently continued hemorrhages, persistent dysenteric conditions, or too prolonged lactation, have brought the system into a condition of lowered vital resistance. Unfortunately, in ordinary life these run-down physical conditions are prone to be associated with the worry and overwork that precede disaster.

The effect of grief as a cause of melancholia may best be realised from the fact that in something over one-half of all the cases of melancholia the death of a near relative, father or mother, or even more frequently husband or wife, or child, is found in the clinical history of the patient shortly before the development of the mental disturbance. Serious business troubles, however, loss of property, actual want of proper nourishment, failure to succeed in some project on which the mind has been set, and similar conditions, so common in our modern hurried life, are also capable of producing the mental depression that assumes an insane character in certain individuals.

For the development of melancholia a predisposition seems to be necessary. Most people can suffer the reverses of fortune, the accidents of life, and the griefs of loss of friends and relatives, without mental disequilibration. Certain predisposing factors are well known. Heredity, for instance, is extremely important. Melancholic conditions are frequently found in successive generations of the same family. While heredity is not as prominent a feature in melancholia as in other forms of insanity, the direct descent of a special form of melancholic mental disturbance from one generation to another is noted more frequently than in any other form of insanity.

Women are more often the subjects of melancholia than are men. This is especially true in the earlier and in the later periods of life. In the years between twenty and thirty-five the proportion of cases in each sex is more nearly equal. The two conditions, the establishment of the sexual functions, that is, the important systemic changes incident to puberty, and the obliteration of the sexual function at the menopause, with its consequent physical disturbances, are especially important in predisposing to the occurrence of [{217}] melancholia in women. Their mental functions are less stable naturally, and are subject to greater physical strains and stresses. Childbirth and lactation are also important factors in the causation of the condition. Long-continued lactation—that is, beyond the physiological limit of about nine months—is especially a frequent cause. The development of the mental disturbance in this case is always preceded by a state of intense anaemia, in which the skin assumes a pasty paleness, and other physical signs give warning of the danger. Lactation is sometimes prolonged for no better reason than the hope to avoid pregnancy. Usually we may say this method fails of its purpose and pregnancy and lactation together work serious harm.

In young people particularly, homesickness is a not uncommon cause of melancholia. It is especially liable to produce the condition if young people at a distance from home are subjected to serious mental and physical strain at a time when the food provided for them is either insufficient or unsuitable, or when disturbances of their digestive systems make it impossible for them properly to assimilate it. A number of instructive examples of this condition have occurred in the last few years among our young soldiers in the Philippines. To the physical strain necessarily incident to campaigning, especially in young men unaccustomed to the life of the soldier, there was added the serious trial of the tropical climate and the unusual and not over-abundant or varied diet provided by the army rations.