Grief





Grieving would seem at first glance to be one of the conditions for

which the physician, especially if the etymology of the name of his

profession be taken strictly, should not be called upon to minister,

nor his remedies be expected to relieve. Grief is usually supposed to

be due to moral ills and, therefore, at most to come under the care of

the alienist, with the feeling that even he can accomplish very little

for what is an affective rather than a true mental disorder. There is

no doubt at all, however, that grieving, especially in the excess that

shows it to be pathological, is always associated with certain

physical and mental conditions for which the physician can accomplish

much. Indeed more often than not the physical condition of the

grief-stricken person is a prominent factor in the production of the

state of feeling which causes grief to be exaggerated, while, on the

other hand, this state of mind itself reacts upon the physical

being so as to make it more sluggish in all its functions, and as a

consequence a vicious circle of cause and effect is formed affecting

unfavorably both the mental and physical conditions. It is when

patients are run down in health that grief becomes extremely difficult

or apparently impossible to bear and grief itself still further brings

about a deterioration of health that makes the mind's reactionary

power against its gloomy feelings still weaker than they were.



Viewed in this way, grief is an ailment that should properly come to

the physician for treatment and with regard to which that important

principle is eminently true that the physician cannot always cure, but

he can nearly always relieve, and he can always console his patients.

On the one hand, an improvement in the general health always make

grief easier to bear because it increases the resistive vitality of

both mind and body. On the other, any diversion of mind that lifts the

burden of grief even to some degree, releases new stimuli and physical

powers for the restoration of bodily function to the normal and this

brings about an immediate lessening of the depressive condition. In a

word, for the vicious circle of unfavorable influences ever pushing

the victim farther into depression, a virtuous circle, in the Latin

sense of the word virtue, meaning courage, favoring strength, must be

formed, that brings about an immediate improvement in the patient's

mental and physical well-being. This is not a pretty bit of theory but

is the result of the experience of every physician who has ever taken

seriously the problems of caring for the grief-stricken.





Natural and Pathological Grief.--It is, of course, not easy to

distinguish between grief that may be called morbid in the sense of a

melancholy, that is, more than natural--a true mental disease--and

that which represents only an affective state accompanied by

depression from which there will be complete reaction. A mother loses

a favorite, it may be an only son, and is plunged into grief. For

days, even weeks, she refuses to take any interest in life, she thinks

moodily about the awful affliction that has come to her and how blank

the future is, and she cannot be aroused to attend either to her own

affairs or to the duties of life around her. Such a grief is, in many

cases, not more than the normal depression incident to such a loss. If

after months, however, the mother still continues to refuse to take

interest in life and the things around her, especially if, besides,

she now talks of having been visited with this punishment because of

some unpardonable sin in her own life, or because the Deity has been

offended beyond all hope of propitiation, then the case verges over

into one of true melancholy in which the mental depression is not

merely a symptom of a passing condition, but partakes of the nature of

a mental disease, or is the consequence of a profound neurotic

condition.



It must not be forgotten that there is always the danger that

exaggerated grief, as it seems for the moment to be, may be only the

first symptom of a true melancholic condition. Only too often friends

and physicians have been deceived by this. Some of the sad cases of

self-destruction and a few cases of homicide and suicide have followed

a condition that seemed to be only abnormal grief for the loss of a

relative.





Etiology.--The cause of exaggerated, prolonged grief is, in a

considerable proportion of the cases, a melancholic tendency, that is,

a failure on the part of the mind to react against depression.

The weakness of mind that predisposes to this may be inherent or

acquired. Sometimes no special loss is needed to produce melancholia

in susceptible individuals, while occasionally it is precipitated by

some misfortune, inasmuch as this is a mental disease, very little can

be done directly, and yet the patient can be helped and diversion of

mind may bring a good measure of relief. More often, however, the

reason for persistent grieving is that before the disturbing loss came

into the life of the individual there had been a serious deterioration

in health. This was due to the conditions preceding the unfortunate

event. Wives sometimes have worn themselves out physically and

mentally while nursing husbands, or mothers their children, and this

has produced a lack of physical force which prevents them from

reacting with healthy mentality against the subsequent shock of loss.





Prophylaxis..--For the melancholic tendency prophylaxis cannot be

special, but must be general. We cannot prevent people from suffering

serious losses, but we can foresee the possibility of a loss proving

very depressing, and can, therefore, try to keep the individual in

reasonably good physical condition. If this is done the subsequent

depression will be much less than it otherwise would be. Very often

there is little or no recognition of the fact that there is a definite

tendency in some patients to too great an inclination toward

melancholic thoughts, and it is not until an exaggerated manifestation

of it comes that the danger is realized. It is not easy to make

patients realize the dangers, but where the physician talks with

assurance and points out definite things to do in order to prevent

serious developments, patients, or at least their friends, can be made

to appreciate the dangers.



The best demonstration that I know of the value of work as a remedy

for grief is my experience with members of religious orders. For them,

as a rule, there is no interruption in life no matter what the loss

may be. Their work goes on the day after the funeral just as before.

This is the most precious possible arrangement, time and occupation of

mind are the two factors that will dull the edge of grief and while

humanly we may resent the consolation that is thus brought by such

conventional things as the passage of time and humdrum occupations,

they represent nature's resources. Above all, patients must be given

something to do and if that something concerns other suffering human

beings, there is every reason to expect relief.





Treatment.--The most important element in the treatment of grief cases

is to prevent physical running down as far as possible and to build up

the physical condition. Depression that comes to patients who have

lost considerable weight, even though it may show some of the signs of

melancholia, is always hopeful. Where patients are twenty or thirty

pounds under weight the recovery of weight up to the normal condition

will often mean the relief of their depressed condition. The one hope

lies in this physical improvement. Mental treatment by diversion of

mind must, of course, be practiced. This does not mean getting the

patients interested once more in trivial things, but to be successful

it means arousing the deeper feelings of their nature. Above all, the

solace of tears will often save depressed and grieving persons from

themselves. An interest in the sufferings of other people that awaken

their sympathy will do the most to end exaggerated grieving over their

own loss. The self-centeredness of their grief is the principal reason

for its exaggeration. It is because of overestimation of their

own importance and of the importance of their loss that these people

suffer severely.





Motives of Consolation.--The main resource of the physician who

would employ psychotherapy for the treatment of those who are grieving

beyond the limit of what is normal, is to supply motives by which they

can understand the real significance of their loss. Very often,

especially in young folks, there is no proper estimation of values in

life and no recognition of the fact that human life was evidently not

meant for happiness since that comes to but few, while suffering and

partings are inevitable. They come to all, and apparently will always

continue to do so. It is the young or, at least, those under middle

age, who are most likely to be affected by exaggerated depression over

losses and disappointments. Older folks have grown more accustomed to

such incidents. These patients must be made to see how many motives

there are to take their grief philosophically and while permitting

themselves the luxury of sorrow, not to let this interfere either with

their physical condition or their mental state to such a degree as to

prevent them from taking the proper interest in their duties in life.



The ethical motives that may be urged to keep people from grieving

over-much are many, but there is sometimes the feeling in the

physician's mind that it is scarcely his business to emphasize them in

any way. It is supposed that to the clergyman must be committed the

task of consoling people for losses in life. This has always seemed to

me a serious mistake. As physicians we know how much the mind

influences the body and since it is our duty to care for the body, we

must, above all and first of all, care for the mind as far as we can.

Mens sana in corpore sano is a very old motto and is usually taken

only in the sense that to have a healthy mind one must have a healthy

body. In its Latin form, however, it might very well also be taken to

mean that to have a healthy body one must have a healthy mind. Since

grief has an untoward influence on the body, physicians are bound to

learn what to do for it in any and every possible way and to exercise

every faculty they have for its relief. This is all the more true

because in recent years many persons have no regular religious

attendant who would come to offer them consolation or to whom they

would go in their trouble. It is not at all with the idea of

infringing on the rights of the clergy or invading his territory that

I would insist not only on the right of the medical man, but even his

duty, to afford consolation to the mind as well as relief for the

body.





The Family Physician.--In older times the family physician was a

friend of the family to whom people turned in all troubles where he

might possibly be of aid, with just as much confidence and as promptly

as they did to their religious attendant. Unfortunately, in the

progress of medicine, though still more because of the social

vicissitudes that have taken place in recent years, this relationship

of the family physician has been largely diminished, but that

constitutes only one more reason why every physician, to whose

attention the grief of a patient for any loss is presented as a cause

of ill-health, should know all the means and be ready to employ them

for the amelioration of the condition. As a matter of fact, there is

often a feeling on the part of patients that it is more or less the

business of the clergyman to afford consolation and that the

performance of his duty in this matter is somewhat conventional, not

as if he performed it less thoroughly because of this, but as if

the feeling of the routine practice detracted from its effectiveness.

Some of the motives for consolation advanced by the clergyman, then,

lose in significance, in some persons' minds at least, because of this

feeling, while motives presented by the physician rather gain in

weight because of the impression that he is a thoroughly practical

man, deeply interested in life's problems from a common-sense

standpoint, and who knows the motives for consolation because he has

realized that losses are inevitable, suffering unavoidable, and grief

sure to come, though somehow we must learn to bear up bravely under

life as we find it.



Physicians have always done this in the past, but in more recent years

either they have lost the habit, or have considered it unworthy of

their profession, or else, perhaps, only too often they themselves

have had no motives to offer that might seem sources of consolation

for those in suffering and especially those who are grieved for the

loss of friends. If life were a mere chance, if there were not an

evident purpose in it, if, as Lord Kelvin insisted, science did not

demonstrate (not "suggest" but "demonstrate" is the word he used) the

existence of a Creator and a Providence, Who, while caring for the

huge concerns of the universe, can just as well employ Himself with

the little details of human life, then there would be some reason for

physicians thinking that their science kept them from seeking

consolation from the ordinary motives. Even if they occupy an advanced

agnostic position, however, they may still find sources of consolation

that, if not so effective as those attached to the old beliefs, at

least will provide something for the forlorn to take hold of, that

will mitigate their grief and sense of loss and make the present and

the future look not all too blank.



Few men have been so thoroughly agnostic as Prof. Huxley, yet on the

death of his wife he found that some of the thoughts of the old

beliefs might prove a source of consolation. Huxley had loved his wife

very dearly and their separation by death meant very much. The epitaph

that he wrote for her sums up his doubts yet plucks out of them

something to console, expressed in old Scriptural language:



And if there be no meeting past the grave.

If all is darkness, silence, yet 'tis rest.

Be not afraid, ye waiting hearts that weep.

For God still giveth His beloved sleep;

And if an endless sleep He wills, so best.





Attitude Toward Death.--The ordinary attitude of people toward death

is a very curious one. Death is the one absolutely certain thing in

life after birth, yet most of us live our lives without much regard to

it, and whenever it comes and under whatever circumstances, at

whatever age, it is always a shock to us. No matter how old people are

it always comes a little before it is expected. When death comes it is

always a shock and all that can be said of it is what Hamlet resents

when the commonplace consolations for the loss of his father, who also

lost a father and so on all down the course of history, are offered to

him. Perhaps, however, as much the reason for his resentment was the

person who offered the consolation as the form of the consolation

itself, which, after all, exhausts nearly all that we can say in this

matter for grief for near and dear ones:







King.

'Tis sweet and commendable in your nature, Hamlet,

To give these mourning duties to your father:

But, you must know, your father lost a father;

That father lost, lost his; and the survivor bound

In filial obligation, for some term

To do obsequious sorrow: but to persevere

In obstinate condolement, is a course

Of impious stubbornness: 'tis unmanly grief:

. . . Fie! 'tis a fault to heaven,

A fault against the dead, a fault to nature.

To reason most absurd, whose common theme

Is death of fathers, and who still hath cried,

From the first corse, till he that died to-day,

"This must be so."





Death and Pain.--One of the most effective consolations in our day

for all classes of people, quite apart from religious affiliations or

beliefs, is the sociological import of death and suffering in the

world. Life, without suffering and death in it, would be a riot of

selfishness. Men, as a rule, would not care for others at all, the

weak would go to the wall, the individuals who possess less efficiency

than others would simply have to make out as best they could, and bad

as social conditions are now, they would be intolerably worse. As it

is the young and strong and vigorous have very little of true

sympathy. Nothing makes a man feel for others like having gone through

some suffering himself. On the other hand, nothing makes him feel the

impotence of struggling ceaselessly for vain success and the futile

rewards of life than to lose near and dear friends whose share in that

success and joy over the rewards would constitute their only real

value and justification. As a man grows older and has gone through

some of the sufferings and has had to bear the losses of life, he

learns more and more to feel for others, he is ready even to make

sacrifices that others may not have to suffer as he has suffered, he

has charity for them for the sake of his own suffering and that of

near and dear ones, and things are much better than they could

possibly be without suffering and death.





Therapy by Example.--Many men have taken losses so seriously as to

think that life held no more for them, and have foolishly given up

their occupations, yet have found that Time, the great healer, could

work his marvels in their case as well as in most others and that new

interests and, above all, their life work, could arouse them to a

sense of duty and bring them back to the old routine of life. Dr.

Mumford, in his "Sketch of Sir Astley Cooper," tells the story of how

even that veteran surgeon gave up everything at the death of his wife

and yet found, after a year of idleness, that he had to come back to

the old life again. Dr. Mumford says: "Sir Astley Cooper was an

emotional man. In 1827 his wife died, and the event prostrated him

with grief. He felt that all the interests of life were over for him.

He fell into an acute physical decline, sold his town house, threw up

his practice and other professional employments, and retired to his

country place to pass his last days. Within a year of the sad event he

had returned to town, taken another house, resumed practice with

increased vigor, and married again. He was then sixty years old, he

lived on until 1841, and died in his seventy-fourth year."







A typical example of how much a strong man whose diplomatic ability

had stamped him as one of the large men of his generation may yet be

afflicted beyond measure by a loss of this kind is to be found in the

life of the second Lord Lytton. I have told it somewhat in detail in

the chapter on Periodic Depression. After the death of his boy Lord

Lytton, who for more than a week of anguish had watched unceasingly at

the death-bed of his dying son, came to the conclusion that God was

not in His world or, at least, that the arm of Providence was

shortened if such (as it seemed to him) needless suffering was

permitted. The boy had probably suffered much less than the bystanders

thought and much less than he seemed to, for in these cases nearly

always there is a merciful deadening of the senses that to a great

extent eliminates suffering, but Lord Lytton could not understand and

refused ever to look at life from the same standpoint afterwards. This

is, of course, only what happens in many cases, but it represents an

exaggeration of grief since death and suffering have always been in

the world and sometimes they will come to those near and dear to us,

much as we may resent it.



Neither profound intelligence nor the sympathetic genius of the poet

or artist is sufficient to safeguard men against the severer forms of

griefs for loss. Louis, the distinguished French physician (to whom we

in America are indebted so much as the Master of the Boston and

Philadelphia schools of diagnosis, and, above all, for his teaching of

the differentiation between typhoid and typhus fever), suffered so

much from the loss of his son that he could scarcely be consoled.

Dante Gabriel Rossetti was so much affected by the death of his wife

that he put into her coffin the only manuscript copy of his poems that

he possessed. It is interesting to learn that some years later he had

the coffin exhumed and took out his manuscript at the urging of

friends, and published the poems. Many other examples of this kind

might be given, for exaggeration of grief affects all classes and

conditions in life. They are practically always pathological, usually

on a basis of somewhat disturbed mentality, though often the real

underlying and predisposing condition is the physical exhaustion that

has preceded the loss and which makes patients unable to bear the

strain of it after weeks of care, solicitude, anxiety and neglect of

eating and sleep.





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