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.
Autointoxication is said to play a prominent role in the causation of
melancholia. This supposes that there is a manufacture of poisonous
materials within the system, whose transference to the nervous tissues
causes functional disturbance of these delicate organs. Such poisons
are especially liable to be manufactured when digestive disturbances
have existed for long periods of time, or when chronic alcoholism is a
feature of the case. The ordinary depressed condition so familiar in
our dyspeptic friends and that develops so commonly as the result of
indigestion, is an example of the depressing effect of toxic
substances upon nervous tissues and mental states.
{218}
Melancholia does not develop as a rule without some warning of what
may be looked for. Nutritive disturbances are nearly always prominent
features in the case for some time before any mental peculiarities are
noticed. Professor Berkley remarks that a feeling of woe and of
uneasiness seems to be the way by which the brain expresses its sense
of the lack of proper nourishment. Usually there has been distinct
digestive disturbance for some months. There is apt to be loss of
appetite. There may be some slight yellowness in the whites of the
eyes. Commonly there has been an increasing disregard for the
patient's usual habits, especially in the matter of exercise and
friendly intercourse. There is a disposition to sit apart and brood by
the hour, and a well-marked tendency to avoid friends and even members
of the family, with an utter disinclination to meet strangers.
One of the marked features of the disease in women is a tendency to
untidiness. Women lose all regard for their personal appearance and
fail to arrange their clothes properly. Men who have been specially
neat in their personal appearance take on slouchy, careless habits,
allow their clothes to become soiled and dirty, and have evidently
forgotten all their old customs in this matter.
The symptoms are not always continuous. There is often a rhythmic
alteration of intensity of symptoms that corresponds more or less to
the physiological rhythm of life. In ordinary circumstances human
temperature is highest in the afternoon and vital processes are most
active at this time. The lowest temperatures occur in the morning,
especially in the early hours; and it is at this time that vital
processes are least active and the general condition is most
depressed. It is not surprising, then, to find that melancholic
patients are liable to suffer from deeper mental depression during the
morning hours. In suicidal cases it is especially in the morning hours
that patients need the closest surveillance.
In a certain number of cases of melancholia, instead of the quiet,
often absolute immobility of the patients, there is a form of the
disease characterised by the presence of incessant movement and an
agitated state of countenance, {219} that disclose their disturbed
mental conditions. In melancholia, as a rule, sleep is very much
disturbed, and at times patients do not sleep at all. In the agitated
form of melancholia, the patient is often quiet only when under the
influence of a sleeping-potion. Patients may tear their hair,
disarrange their clothing, strike themselves, hit their heads against
the wall, sigh and sob, and repeat some phrase that indicates their
deep depression. They are apt to reiterate such expressions as "I am
lost," "I am damned."
This is a much more serious form of melancholia than the quiet kind.
The mental faculties are much more completely unbalanced, and the
prognosis of the case is more unfavourable. There may be recovery
within a very short time, and this recovery may be more or less
complete. Usually, however, the condition becomes chronic and runs for
many years. Such patients may sometimes be distracted sufficiently
from their state of depression to smile and manifest pleasure in other
ways. Usually, however, this diversion is only temporary and they
recur to their darker moods until some new and specially striking
notion distracts their thoughts once more.
With regard to melancholia the most important feature is the tendency
to suicide. This is apt to be present in any case, however mild, and
may assert itself unexpectedly at any moment. Where there is suspicion
of the existence of melancholia, patients must be under constant
surveillance; and, as a rule, they should be under the supervision of
some one accustomed to the difficulties that such cases may present.
Patients are often extremely ingenious in the methods by which they
obtain the opportunities necessary for the commission of suicide. For
instance, a man who has been calm in his depression and has shown no
special suicidal tendencies may make his preparations apparently to
shave and then use his razor with fatal success. In a recent case in
New York City, a woman under the surveillance of a new, though trained
nurse, asked the nurse to step from the room for a moment. When the
nurse came back three minutes later, the woman was crushed to death on
the sidewalk seven stories below. A male patient asks an attendant
{220} to step from the room for a moment for reasons of delicacy, and
takes the opportunity to possess himself of some sharp instrument or
of some poison. At times, during the night, patients rise up while
attendants doze for a few minutes, and find the means to hang
themselves without the production of the slightest noise.
These unfortunate suicides are happening every day. They are the
saddest possible blow to a family. Only the most careful watchfulness
will prevent their occurrence. Clergymen should add the weight of
their authority to that of the medical attendant in insisting, when
such patients are kept at home, that they shall be guarded every
moment. As a rule melancholic patients should be treated in an
institution. Their chances of ultimate complete recovery, and, more
important still, of speedier recovery than at home are much better
under the routine of institution life and the care of trained
attendants.
Nearly three-fourths of the patients who suffer from melancholia will
recover from a first attack under proper care. Subsequent attacks make
the prognosis much more unfavourable. Not more than one-half will
recover from a second attack, and, although melancholia is often
spoken of as a mild form of intellectual disturbance, recurring
attacks give a proportionately worse and worse outlook for the
patient.
If the general condition of the patient, that is, the physical health,
is very much run down when the mental disturbance commences, then the
outlook is much better than if the mental disturbance should occur
when the patient is enjoying ordinarily good health. Thin, anaemic
patients, contrary to what might be expected, usually recover and
often their recovery is permanent. The first favourable sign in the
case is an improvement in physical health. This is very shortly
followed by an almost corresponding improvement in the mental
condition. When the patient has reached the normal physical condition,
the mental disturbance has usually disappeared.
It is an extremely unfavourable sign, however, to have run-down
patients gradually improve in physical health {221} without
commensurate improvement in their mental condition. This is nearly
always a positive index that the mental disturbance will continue for
a long while, may not be recovered from completely, or may degenerate
into a condition of dementia with more or less complete loss of mental
faculties.
The severe forms of melancholia are apt to be associated with
delusions. Fear becomes a prominent factor, and the patient is afraid
of every one who approaches, or concentrates his timidity with regard
to certain persons or things. Delusions of persecution are not
unusual, and this sometimes leads to homicidal tendencies. After
enduring supposed persecution for as long as he considers it possible,
the melancholic turns on his persecutors and inflicts bodily harm. The
simplest actions, even efforts to benefit the patient by enforcement
of the regulations of the physician, may be misconstrued into serious
attempts at personal injury, for which the patient may execute summary
vengeance. At times the hallucinations take on the character of the
supposition that attempts to poison them are being made. The patient
may conceal his supposed knowledge of these attempts until a
favourable opportunity presents itself for revenging them. On the
other hand, it is not an unusual thing to have melancholic patients
commit homicide with the idea of putting friends out of a wicked
world. The stories so common in the newspapers of husbands who kill
wives and children, of mothers who murder their children, are often
founded on some such delusion as this. A mother argues with herself,
that her own unworthiness is to be visited on her children, and that
they are to be still more unhappy than she is. Out of maternal
solicitude, then, but in an acute excess of melancholia, she puts them
out of existence and ends her own life at the same time.
When the melancholia is founded on supposed incurable ills in the
body, patients are sometimes known to mutilate themselves, or to have
recourse to alcohol, or some narcotic drug, in order to relieve them
of their pain, which is mostly imaginary, and make life somewhat more
livable during its continuance. Alcoholic excesses are especially
common in {222} cases of recurrent or periodical melancholia. Many of
the cases of so-called periodical dipsomania are really due to
recurring attacks of severe depression of spirits, in which men take
to alcohol as some relief for their intense feelings of inward pain
and discouragement.
One of the most characteristic symptoms of melancholia is the refusal
to take food. Sometimes this refusal is the consequence of an
expressed or concealed desire to commit suicide. In many cases the
refusal of food is associated with the patient's melancholic
delusions. If the patient is hypochondriac, food is not taken because
the stomach is supposed not to be able to digest it, or because it
would never pass through the system. At times the delusions are in the
moral sphere and the patient is too wicked to eat, or must fast for a
long period or perhaps for the rest of life, with the idea of doing
penance. As a matter of fact the refusal to eat is associated with the
lowered state of function all through the system, which is the basis
of the melancholic condition. This causes loss of appetite and
lowering of the digestive function with a certain amount of nausea
even at the thought of food, so that it is scarcely any wonder that
patients refuse to take food. Needless to say, they must be made to
eat. This often requires the insertion of a stomach tube and forced
feeding. And as it must be done regularly, it is accomplished much
more easily at an institution than at home.
The other most common type of functional mental disease is mania. This
is a form of insanity characterised by exaltation of spirits with a
rapid flow of ideas and a distinct tendency to muscular agitation. It
is almost exactly the opposite of melancholia in every symptom.
Originally, of course, mania meant any form of madness. Then it became
gradually limited to those forms of insanity which differed from
melancholia. Now it has come to have a meaning as an acute attack of
mental exaltation. It is necessary to remember this development of
signification in reading the older literature on the subject of mental
disturbance.
Professor Berkley calls attention to the fact that Shakespeare's
statement, "Melancholy is the nurse of frenzy," may have been founded
upon the observation that there are {223} few cases of mental
exaltation without a forerunning stage of depression. It is
characteristic of the acuity of observation of the poet whose works
have created so much discussion as to his early training, that this
association of mental states, which became an accepted scientific
truth only during the last century, should have been anticipated in a
passing remark in the development of a dramatic character. Melancholia
precedes mania so constantly that it is not an unusual mistake in
diagnosis to consider a patient melancholic when an outbreak of mania
is really preparing.
Mania is sometimes said to break out suddenly. As a matter of fact
there are always preliminary symptoms; though these are of such a
general nature that they may have escaped observation. The patient's
history generally shows that there has been loss of appetite and
consequent loss in weight, commonly accompanied by constipation and
headache with increasing inability to sleep. Usually these symptoms
have been present at least for some weeks or a month or more. Then the
patient brightens up. Instead of the brooding so common before, there
is a tendency to talkativeness; the eye is bright; the expression
lively; in the midst of his loquacity the patient becomes facetious
and jocular. The backward before become enterprising. Undertakings are
attempted that are evidently far beyond the power, pecuniary or
mental, of the individual. Active employment is sought, and, where
this fails, restless to and fro movement becomes the habit.
Friends notice this change in disposition, and also note a certain
lack of connection in the ideas. There is apt to be a distinct change
of disposition. A man who has been very loath to make friends before,
now becomes easy in his manner toward strangers and takes many people
into his confidence. In the severer forms motion becomes constant; the
arms are thrown around; to and fro movement at least is kept up; the
voice becomes loud and is constantly used. Patients can not be kept
quiet, and, as a consequence of their constant movement, their
temperature rises and loss of sleep makes them weaker and weaker until
perhaps physical exhaustion ensues.
{224}
The causes of mania are not always so distinctly traceable as those of
melancholia. Heredity is an important factor. This is, however, not so
much a question of actual direct inheritance of mental disturbance
from the preceding generation, as a family trait of mental weakness
that can be traced through many generations. Direct inheritance of
acquired peculiarities no scientific thinker now admits. Family
peculiarities, however, are traceable through many generations. So
striking a peculiarity as the possession of six fingers or six toes
has been traced through a majority of the members of as many as five
generations in a single family. And as has been said other family
traits can be traced back in the same way.
It would not be entirely surprising, then, if mental peculiarities and
a predisposition to mental disturbance should be also a matter of
inheritance. It is well known now that the physical condition of the
brain substance may have much to do with the intellectual functions.
Injuries to certain parts of the brain may cause special changes even
of personal disposition. In the famous crowbar case, in which an iron
drill over four feet in length was driven through one side of the
head, it was noted that the man, who had been somewhat morose before,
was inclined to be more amiable afterwards, but also had a tendency to
be bibulous in his habits.
German clinicians have recently pointed out that the existence of an
excess of pressure on the frontal lobes of the brain, such as is
produced by the presence of a tumour, may cause a tendency to make
little jokes. This symptom is known as "Witzelsucht." It is considered
of distinct significance and value in localising tumours of the brain.
The question of the type of the witticisms and particularly a tendency
to obscenity are noted as a special diagnostic aid in the recognition
of the character of these tumours by at least three prominent German
medical observers.
If modifications of the brain substance can produce changes of
disposition and temperament, it is easy to understand how temperament
and disposition may be a matter of inheritance. If we inherit a
father's nose and a mother's eyes, {225} the minutest conformations of
brain substance may also be inherited. It is on these, to a certain
extent at least, that the general outlines of the disposition depend.
It would not be surprising to find, then, a disposition to mental
unsteadiness as the result of the transmission of brain peculiarities.
Here, as in everything else, there is question, not merely of parental
influence, but of the inheritance of the family traits, some of which
are skipped in certain generations.
When melancholia and mania are said to be due to heredity as one of
the principal causes, the meaning intended is that in certain families
the brain tissues are liable to be transmitted in somewhat impaired
condition, and that through these brain tissues the mind will either
not act properly, or under the stress of violent emotion, the loss of
friends by death, or the loss of fortune, or serious disappointments
in life, or a love affair, the already tottering mental condition will
be overturned. In a word, it is not the direct transmission of
insanity, but of a predisposition to the development of insanity under
stresses and strains that is a matter of family inheritance. This is
considered true now not only of mental but of all diseases. Not
consumption, but the predisposition to it is inherited.
These considerations make clear how important this matter of heredity
is. Physicians and students of anthropology are so much concerned
about the increase of insanity as the result of the intermarriage of
defectives that we are constantly reading in the newspapers of
attempts at the legal regulations of marriage, so as to prevent
further racial degeneration. Under present circumstances, any such
legal regulation is probably impossible; but it seems perfectly clear
that clerical influence should be brought to bear to discourage, as
far as possible, intermarriage among those of even slightly disturbed
mental heredity. Especially must any such idea as the possible
beneficial influence of matrimony (for there are popular traditions to
this effect) be unhesitatingly rejected and it must not be allowed to
tempt those interested to look on such intermarriage with
indifference.
{226}
Another and more serious question for the clergyman is that of the
vocation in life of those who are weak mentally. By vocation is meant
not only religious calling, but the occupation in life generally.
Young people of unstable mentality and especially those of insane
heredity should be advised against taking up such professions as that
of actor or actress, or broker, or other life duties that entail
excitement and mental strain. As far as possible they should be
discouraged from taking up city life, and should be advised to live
quietly in the country.
Mania is apt to follow certain severe infectious diseases in delicate
individuals. Pneumonia, for instance, or typhoid fever or chorea, and
sometimes consumption or rheumatism, may be followed by a period of
maniacal excitement. Severe injury to the brain or the pressure due to
the presence of a brain tumour, may also be a cause of mania. A
certain number of good authorities in mental diseases have called
attention to the fact that mania is a little more liable to occur in
patients who are suffering from heart disease. By this is meant in
persons who have some organic lesion of the valvular mechanism of the
heart. This leads to disturbance of the circulation and interferes
with cerebral nutrition, thus predisposing to functional brain
disturbance.
While melancholia occurs very frequently in older people, mania is
almost essentially a mental disease of the young. The vast majority of
cases occur between the twelfth and thirty-fifth year. The subjects of
the disease are usually those who possess what is called the sanguine
temperament, that is, hopeful, enthusiastic people, easily excited and
aroused, easily cast down. Mania is much more common in females than
in males.