Heart Disease.—Periods of depression are also common in heart disease and are often the first symptom of the beginning of a break in compensation. This effect is not so simple and direct, however, as in the case of the kidneys. Probably the first physical symptom of a break in compensation, where there is real valvular heart disease, is a decrease in the amount of urine. This points to an insufficient elimination of the products of metabolism and to the retention in the circulation of toxic substances. The reason for this is the lessened circulation through the kidneys because of the diseased heart. There is also a lessened circulation through the brain. This impairs the function of the brain and quite naturally leads to mental depression, slowness of decision, and unwillingness to occupy one's self with many things. Besides, because of the lessened function of the kidney the circulating blood not only does not nourish so well but it tends still further to depress the brain cells by the toxic substances that are in it. Depression in such cases is rather to be expected and at the beginning is not continuous but comes in ever longer periods with shortening intervals as the disturbance of the circulation progresses. At first, like other diminutions of function, it is conservative in order to spare the heart work.
Respiratory Affections.—Very curiously an affection of the lungs has exactly the opposite effect and is likely to create in the patient an artificial sense of well-being. Spes phthisica, the characteristic hope of consumptive patients, is well known, and has been described by many a careful observer from Hippocrates and Galen to our own time. A lessened amount of oxygen in the blood produces a certain sleepiness, but this seems to be preceded by a period of slight excitation. The most familiar example of this occurs at the beginning of the inhalation of laughing gas. Practically the only direct physical effect of the inhalation of nitrous-dioxide is to shut off our oxygen and it is a slight period of deoxygenation that produces the anesthesia by this agent. Whether we have not in this the explanation of the feeling of the consumptive, so that often on the day before his death he plans a number of things that he is going to do next year, may require more careful [{643}] investigation, but the suggestion may serve to show how much disposition, both lively and serious, depends on physical factors as well as on the natural state of mind.
MENTAL STATES OF DISAPPOINTMENT
Quite apart from these serious ailments, however, there are passing phases of depression that come to nearly everyone after adult life is reached that are likely to be somewhat more frequent as years go on, but that are not entirely unknown even in early years. They are more likely to come to those who feel that life has been somewhat of a failure and that they have accomplished very little in spite of all that they have tried to do. Not infrequently they come, however, to those who in the estimation of other people have made a magnificent success of life. The rich man, after he has made his fortune, unless he continues to engross himself with some time-taking and interest-claiming work, may be the subject of repeated attacks of mental depression. Social leaders among women who begin to feel something of the emptiness of social striving, after they have made what is called a success in society and at the time when they are the envy of many on the social ladder below them, are particularly likely to be subject to attacks of "the blues." The only men and women who are free from them to a great extent, and even they not absolutely, are those who are busily engaged with some occupation not entirely selfish in which they can see that what they are doing is accomplishing something for the people around them.
Very often an attack of depression is ushered in by some small disappointment. As a rule, however, this is not the causative factor but is only an occasion which makes manifest the depressed state that has existed for some time and that now declares itself openly. In the same way only a slight occasion is necessary apparently to dispel clouds that hang over a person in the milder attacks of depression, because, for some time before, relief has been preparing itself and a livelier phase of existence has been gradually coming on. Relief can be promised with absolute assurance, but freedom from relapse cannot be assured and the only true source of consolation that is helpful is the frank recognition of the fact that these are successive phases of existence quite as likely to be periodic as certain physical facts in life. Depression is likely to be a little more manifest in the morning than at other times, partly because the interests of the day have not yet come to occupy the mind, but mainly because the physical life as indicated by the pulse and the temperature is lower during the morning hours than in the afternoon and evening. Just as soon as people realize the physical nature of certain dispositional changes they give much less depressive significance to them.
Occupation of Mind.—The most important feature of the treatment of depression of mind is to secure somehow such occupation as will catch the attention and arouse the interest. This is not always an easy matter. How effective it is, however, can be best judged from what one notes of the effect of such things as physical pain or great solicitude for someone else besides themselves. I have known a mother, whose fits of "the blues" were getting deeper and the intervals growing shorter to be roused from her condition when all means had failed by the elopement of a daughter who had been partly pushed into leaving because things had become so unpleasant around home [{644}] during her mother's depression, and any change seemed welcome. On the other hand, I had a doctor friend who felt quite alarmed about his growing depression and who even had some fears lest, if it continued to deepen, he might commit suicide. He was completely lifted out of his increasing depression by the occurrence of pneumonia in his boy of sixteen. The pneumonia did not end by crisis but by lysis and for weeks he had very little sleep. He confessed that the intense preoccupation of mind had completely driven away his blues and had even done much to relieve him of various digestive symptoms to which he had previously attributed his depression.
Again and again I have known men who, in the midst of prosperity, found life dull and rather hard to bear, and who just as soon as a crisis in their affairs compelled them to pay attention to other things than themselves and the state of their feelings, grew better mentally and physically. It seems almost a contradiction in terms to say that it is the man of little occupation, as a rule, or at least of occupations that are not insistent, who is likely to be troubled with insomnia, while the very busy man, especially the man busy not about one or two narrow interests, but about a number, is seldom so bothered. Nothing contributes more to the depression of mind than loss of sleep or supposed loss of sleep. Even women who, while living in ease and comfort, had much to complain of as regards depression, often lose entirely their tendencies to "the blues" or have fits of them at much longer intervals, when necessity compels them either to earn their own living or, at least, to occupy themselves much more with absolutely necessary duties.
Provision of Occupation.—It is a hard matter to create such occupation of mind as will be satisfactory. Patients have to be tried by various suggestions. The tendency to periodic fits of depression deep enough to be called to the physician's attention is much more noticeable in recent years than it used to be, and seems to me at least to bear a corresponding ratio to the decrease of home life. Home duties usually mean joys and of late there has been a neglect of the joys of life while seeking its pleasures. Certain phases of city life are responsible for much dissatisfaction with existence and depression of spirits. Most of the women who live in apartment hotels have practically no serious occupation of mind. They need not get up if they do not feel quite right or quite rested—and who after the age of forty ever does feel quite all right in the morning hours unless sleep has been in the open air? Nothing is so likely to start a day of depression than failure to get up promptly, lounging around with forty winks here and there, reading in bed, and the like. If breakfast is taken in bed, then some reading indulged in, and then some sleeping, and only an hour or two of dawdling around comes before lunch, that meal is not properly enjoyed and the afternoon is started badly; unless there is some special diversion of mind depression is almost sure to get the upper hand.
Place of Children in Psychotherapy.—Where there are children the interests are much more urgent and there is little time for such preoccupation with self as gives one "that tired feeling." We are very interesting to ourselves, but just as soon as we have no other subject to occupy us than ourselves we soon grow very tired of the subject. Children are the best interest that one can think of, for women particularly. When they have none of their own an interest in orphan asylums, in day nurseries, in various children's [{645}] institutions, and, above all, in the adoption of a child, will do more than anything else to relieve the tendency to blues. Of late years the adoption of children has been much less frequent than used to be the case in childless families, and doctors see the result in mental depression. Children are a great care, but they are a great blessing to women, and while the present trend of social life eliminates them as far as possible, this elimination, beginning with their relegation to nurses when they are infants, to nursemaids as they grow a little older, and then to the kindergarten up to six years of age, far from adding to comfort rather increases the discomfort of many mothers. Nature takes her revenge. The reason why the mothers of past generations could stand the suffering that they must have borne with patience before gynecology developed to relieve them, was that they had their children around them, and their minds and their hearts and their hands were so full that they had no time to think of themselves, to brood over their ills, and consequently these troubled them much less than would otherwise have been the case.
Delicate mothers really interested in their children undoubtedly suffer very little compared to delicate women who are alone in life, and what is thus true of the mother is true also of those who have the care of children. It is not alone a satisfaction of the maternal instinct, but it is an occupation of mind and heart with cares for little ones. Other people's children serve just as good a therapeutic purpose, if only their necessities are imposed on the attendant. The reason why women in religious orders have such happy peaceful lives and are happier in spite of a routine of life that would seem to be fatal to happiness, is that their minds are filled with the interests of others, every moment of their time is occupied, and, above all, they have to care for children, the ailing, the poor, sometimes the vicious, who make many demands on them, many calls on their sympathies and keep them from thinking about themselves.