CHAPTER XI.

MELANCHOLIA.

MELANCHOLIA is a form of mental derangement characterized especially by more or less profound depression, with retardation of intellection, with retained consciousness, developing in its progress secondarily delusive ideas, chiefly of self-accusatory nature, sometimes also extreme agitation, and often with intensely suicidal and homicidal tendencies.

In its mildest forms melancholia consists of simple depression with often vague feelings of unworthiness and wrong-doing, but without any real intellectual defect; it is in this stage a purely emotional disorder. The feelings of unworthiness are not delusions, because the patient has no real faith in them; he appreciates their unreasonableness, and resists them to the best of his ability. In this form it is probably the most common of all mental derangements, and as a transient experience is known to a very large proportion of rational individuals. An ordinary severe attack of the "blues," the manifestation in consciousness of a disordered digestion or a temporary toxemia from constipation, is really nothing less than an instance, short and fleeting, of this mildest type of melancholia. When, as the result of original predisposing weakness, or the changes incident to failing powers with advancing age, or as the result sometimes of special toxic or other influences seriously affecting the system and the action of the emotional controlling organs of the nervecenters, this condition becomes more or less permanent, we have melancholia. There are many persons living in the community and taking a part in active life who

have been and are subject to attacks of emotional depression under favorable conditions, and yet whose disorder, though temporary and subject to repetitions, cannot be considered periodic, as it always is the result, in their opinion, of some adequate physical cause; they are psychic neuralgics, and, as in the case of the purely physical neuralgia, the disorder is only the expression of a nervous weakness, occasionally revealing itself under conditions of special stress. It is a question, indeed, whether or not we can speak of a quasi-physiologic melancholia of short duration, occurring sometimes under such conditions. Some phases of religious experience in certain individuals would almost seem to justify the term, and they may occur in individuals once in a lifetime and in those who cannot be accused of any special mental weakness or failure.

While pure melancholia is largely a disorder of advanced life, we cannot follow Kraepelin in classing it amongst the senile mental disorders. It may and often does occur in youth, and in the prime of life. It is probably because it most frequently appears in its milder form at these ages, and does not progress to a stage that disables the patient from following his usual occupation, or to apparently require asylum treatment, that they are very commonly overlooked, and unrecognized. Including these cases, melancholia is one of the commonest, if not the commonest, forms of mental disorder.

Etiology: The chief causes of melancholia besides. predisposition are sudden emotions, such as grief and chagrin, shock, long-continued depressing surroundings, especially if associated with defective or insufficient nutrition, overwork under the same conditions, and intoxications of various kinds, especially if due. to retained waste products in the system. The changes in the brain from beginning old age also seem to specially favor its occurrence, hence its inclusion by

Kraepelin among the insanities of senility. It is rather more common amongst women than amongst men, and amongst the northern than the southern peoples, according to some investigators. It seems probable, for some reasons, that it is more common in civilized and highly cultured communities than are some other types of acute insanity, and its frequency is on the increase, as it is one of the more direct results of the stress of modern civilization.

Nostalgia, or homesickness, in its aggravated form may be considered as a special type of melancholia, which, without self-accusatory delusions, as a rule, tends to intense depression and sometimes to suicide. It is caused by removal from home scenes and by monotonous or unaccustomed surroundings, and is common among fresh recruits in armies; usually it has for its subjects those of rather limited intellectual resources, and of narrow previous experience. Depressing and unusual environments are generally associated as causes, and it is said to be specially frequent in mountaineers removed from their native hills and transferred to a plain or level country. Something approaching it is also experienced by those who have always lived in a level country and are transferred to deep valleys, which have a directly depressing influence upon them.

Melancholia from toxic agents is probably more common than is supposed, but it is likely to be temporary. The action may be directly on the circulation of the brain, but possibly more often on the nerve-cells affecting their nutrition. If the exposure to the toxic action has been brief, as in the case of surgical anesthesia, for example, which has been known to produce this form of mental derangement, the disorder is likely to be temporary. One case was observed by us in which the use of nitrous oxid for the removal of a tooth caused a marked and peculiar type