Part 20

Besides, confessors and religious friends and advisers often gain the confidence of the mentally diseased much more fully than any one else. It is to them especially that the earliest symptoms of beginning mental disturbance are liable to be first manifested. After all, a pastor's and a {212} confessor's duty is bound up with the welfare of his spiritual children in every sense; and it would be supremely serviceable to the patients themselves and to their friends, if these earliest symptoms could be recognised and properly appreciated, and due warning thus given of the approach of further mental deterioration.

The mental diseases that are of special interest in this respect are the so-called idiopathic insanities. Idiopathic is a word we medical men use to conceal our ignorance of the cause of disease. Idiopathic diseases are those that have come of themselves, that is, without ascertainable cause. As a matter of fact, the most important group of mental diseases develop without presenting any alteration of the brain substance, so far as can be detected by our present-day methods of examination. The initial symptoms of these diseases, then, are of great importance, and not readily recognisable unless looked for especially. There is no physical change to attract attention, and the change of disposition and mental condition is often insidious and only to be recognised by some one who is in the confidence of the patient. It is in these idiopathic insanities, then, that the careful observation of the clergyman is of special significance. Needless to say, powers of observation to be of service must be trained.

While there are no known changes in the brain tissues in these diseases, it seems not improbable that the development of our knowledge of brain anatomy, which is especially active at the present time, will very soon demonstrate the minute lesions that are the basis of these mental disturbances. It seems not unlikely that the underlying cause of so-called idiopathic insanity is usually some change within the brain cells. Hints of the truth of this conjecture are already at hand. Meantime the actual observation of this class of patients in asylums and institutions, private and public, and the collation of the observations of authorities in psychiatry from all over the world, have thrown a great deal of light on these forms of mental disease. We know much more of the initial symptoms and of incipient conditions that threaten the development of mental {213} disequilibration than we did twenty-five years ago. With regard to prognosis especially, recent publications have added considerably to our knowledge, although it must be confessed that they have rendered our judgment of such cases much less hopeful.

The ordinary forms of mental diseases have sometimes been considered as passing incidents in the lives of patients suffering from such disorders. While it was generally understood that severe cases were apt to have recurrences, and that after persistence of mental symptoms for a certain length of time the outlook as regards eventual absolute cure is rather dubious, yet the general prognosis of such simple states as melancholia or simple mania was not considered to be distinctly unfavourable. Patients might very well recover their mental sensibility after even a severe attack, and never have a relapse.

It was something of an unpleasant surprise to the medical world, a few years ago, when one of the most distinguished authorities in Europe on the subject of mental diseases, Professor Kraepelin, of the University of Heidelberg, stated in his text-book of psychiatry, that among a thousand cases of acute mania he has observed only one in which the symptoms did not recur. Professor Berkley, of Johns Hopkins University, Baltimore, a conservative American authority, in discussing this subject of relapses after single occurrences of mania, is evidently of the opinion that Professor Kraepelin's opinion in the matter presents the inevitable conclusion that must be drawn from recent advances in the clinical knowledge of maniacal conditions. "Simple mania," he says, "is, according to the statistics now at hand, an exceedingly rare form of mental disease, and the physician should therefore be cautious in making a prognosis of final recovery. Relapses after a number of years, when stability is apparently assured, are frequent, as every one interested in mental medicine knows only too well."

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.

Autointoxication is said to play a prominent rôle 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.