Malankholia (Melancholia)

Malankholia (Melancholia)

Introduction

Melancholia (Malankholia) is a mental condition and especially a manic-depressive condition which is characterized by extreme bodily complaints, depression and often hallucinations and delusions. Psychiatric illnesses were widely recognized in the ancient world. Melancholia and Hysteria were identified in Egypt and Sumaria as early as 2600 BC.

As per Galen (Jalinus) quoted by Zakaria Razi in his world renowned treatise “Kitab Al-Havi.”  It is defined as a disorder in which the mental functions are deranged and the affected person is more prone towards constant grief, fear and dubious aggression. His ability to analyze and interpret things is grossly affected.

Melancholia comes from Greek word “melaina chole” [also ‘lugubriousness’ originated from the Latin ‘lugere’ (to mourn) and moroseness from the Latin ‘morosus’ (fastidious habit, self-willed), wistfulness from the old English ‘wist:’ (intent)].

According to Hippocrates (Buqrat) (a renowned scholar of Unani Tibb) and other Unani scholars it is caused by an excess of black bile. The term melancholia literally means “black humour” which is the predominant causative factor. Mental ill-health is one of the most disturbing and disabling disorders of life which affects not only the concerned person but also his family with social stigma attached to it.

In Global scenario the prevalence of psychiatric illness is almost same. Which is approximately about 8 to 10 per 1000 population. The problem is rising day by day due to some factors like industrialization, urbanization and increase in lifespan, along with breakup of the joint family system etc.  

Melancholia (Malankholia): Unani Philosophy

Unani system of medicine which is an age old traditional system has described it in various classical texts not only the concept but also its management with various modes of treatment. These philosophies and management if pursued will mitigate the suffering humanity to a great extent.

In Unani system of medicine the psychiatric nosology is also a part of medical classification under the title of “Amraze Nafsani” (psychiatric disorders) where all the diseases are classified as syndromes rather than an individual disease entity. These diseases are categorized based on the theories and philosophies of primarily of Hippocrates followed by Plato and later Arabs. Buqraat (Hippocrates: 460 to 370 BC) is usually regarded as the one who introduced the concept of psychiatric illness into medicine. His writings described acute mental disturbances with fever (delirium), acute mental disturbances without fever (probably analogous to functional psychoses but called mania), chronic disturbance without fever (called melancholia), hysteria (broader than its later use), and Scythian disease (similar to transvestism).

According to the philosophy of Unani medicine, proper maintenance of health, management of disease and its manifestations are innate process. Hence proper and normal functioning of the bodily process must be ensured to maintain sound health all physical, mental, social and spiritual type.

The doctrine of Unani system of medicine is based on four bodily fluids i.e. humoral theory viz; Dam (Blood), Safra (Yellow Bile), Balgham (Phlegm) and Sauda (Black Bile). Any disturbance in the normal humoral balance in the human body either its qualitative or quantitative derangement, it leads to disease.

The human body is constituted of seven natural factors (Umoor-e- Tabai’ya), among which four are materialistic (Maddi) viz; Arkan (elements), Akhlaat (humours), Aaza (organs) and Arwah (pneuma) and three are non-materialistic (Ghair maddi) viz; Mizaj (temperament), Quwa (faculties) and Afaal (function).

Derangement or absence of any one of the component results in the development of disease or death of an individual respectively.

Much emphasis is given to the prevention of disease rather than its cure in Unani medicine. It stipulates six essential factors (Asbab-e- Sitta Zarooriya) which advocates on the maintenance of proper balance / equilibrium of these factors. These are:

1. Hawa-e- muheet (Atmospheric air)
2. Ma’kul-wa- Mashrub (Foods and Drinks)
3. Harkat-wa- Sukun Badani (Bodily movement and Repose)
4. Harkat-wa -Sukoon Nafsani (Psychic movement and Repose)
5. Naum-wa- Yaqza (Sleep and Wakefulness)
6. Istifragh-wa- Ihtibas (Evacuation and Retention).

After going through the above mentioned principles, it is clear that the concept of mental health has been in vogue in Unani system of medicine since begining. Failure to maintain balance in Harakat- wa-Sukoon Nafsani results in disability of Qoowat-e- Nafsaniya (mental faculty) includes thinking which comprehend melancholia (malankholia).

It is fact that disturbance in sleep and excessive wakefulness also leads to psychological disorders. Likewise accumulation of morbid materials (mawaad-e- faasida) which is supposed to be habitually evacuated from the body through some means i.e.  menstruation, epistaxis, hemorrhoids, paroxysmal melancholic emesis etc. their retention in the body may pave way to melancholia (malankholia).

Etiology of the Disease (Asbab-e- Marz)

Hippocrate (Buqraat) stated that when there is heat (Haraarat) and dryness (Yaboosat) of stomach (fawad) and coldness (Buroodat) of brain, then such persons are more prone for melancholic diseases (Saudawi amraaz). Sometimes temperament pneuma (Mizaj-e- Arwah) is deranged due to various factors, and this may also give rise to melancholia (Malankholia).

According to Ibn-e- sina (980-1037 AD), only the pathology lies in the brain of an individual (Dimaagh) whereas the real source of disease is either the stomach, uterus or accessory organ of brain in which warm-e- haar (hot swelling) exists.

Ibn-e- sina also stated that sometimes vapours (bukharaat) reach the brain and vitiates the fluids (rutoobaat) by combustion (Ihtaraaq), due to which there is excess of heat (hararat) and dryness (yaboosat), ultimately resulting in melancholia (malankholia).

The other cause for melancholia (Malankholia) is Maadi amraz particularly at the culmination of acute ones. Affected persons from this grave type usually remember death and dead ones. In less severe type of melancholia (Malankholia) the affected person are exhilarant.

However melancholia (Malankholia) is caused mainly due to black bile (Saudavi madda) or mirra sauda. In either case there is preponderance of black bile (Saudavi khilt) particularly associated with combustion (ihteraaq), at that time it is termed as malankholia saudawi.  

When it is caused due to ehteraq of dam or safra or Balgham then it is expressed as malankholia damvi, safravi and balghami respectively.

Sometimes the most likely causative factor is extreme gham (grief), khouf (fear), involvement of fikr (thought) and excessive bedaari (wakefulness).

Accumulation of mawaad (morbid materials) which is supposed to be habitually evacuated from the body viz; menstruation, hemorrhoids, epistaxis, paroxysmal melancholic emesis etc’s retention also leads to malankholia.

According to Ibn-e- Hubl Baghdadi, the causative factor of this disease is the dominance of natural and unnatural black bile (Tabayi wa Ghair Tabayi Sauda) in the human body and the admixture of them with blood and mental/psychic sprit (Roohe nafsani) which results in dimness (Kadoorat), gloominess (Taariki), coldness (Baroodat) and dryness (Yaboosat) which is against the temperament of vital pneuma (rooh), due to which affected person acts insanely with thinking disability.

Black bile (Sauda) is synthesized in the liver (jigar) and stored in the spleen and reaches the brain through the blood vessels. When it is putrefied it causes obstruction and impedes mental/psychic sprit (Roohe nafsani) which disturbs the cognitive functions. It can also retain in the peritoneum (miraq) and mesentery (masaareeqa) and reaches the brain through obnoxious vapours (bukharaat-e- radiyah). Alogwith when peritoneum is also involved it is termed as Malikholiya miraqi.

In the similar manner, when there is combustion of black bile (ihteraaq-e- sauda) and blood becomes thick, grave type of melancholia (malankholia) is afflicted. Many times, the cause for melancholia (malankholia) is Sue-e- Mizaaj Baarid Yaabis of stomach (fuwad), due to which when vitiated mental/psychic sprit (Rooh-e- Nafsaani) reaches the brain, it disturbs the mental functions. Sometimes the brain and meninges deranged saudawi mizaj itself will be the causative factor for melancholia (Malankholia).

Balghami rutubat rarely causes malankholia, if it undergoes putrefaction, may turn into black bile (Sauda).

Clinical Features (Alamaat)

In the early stage of the disease, patient remains sad without any external stimulus, his thinking is perverted, deserted and he finds himself occupied by loneliness and experiences delusion and hallucinations. Patient mutters with himself, and most of the time remains silent. He feels giddy and tinnitus, sexual and food satiety is unusually increased. The nature of fear varies from patient to patient even few patients get afraid of death, some with animals, while some find themselves obsessed by the falling of sky.

Based on the involvement of humours such as blood (Dam) the patient is fond of laughter, sportive and thinks exhilarantly, if it is yellow bile (safra) patient is mentally hard working and are very hyperactive, in case of phlegm (Balgham) patient is gloomy and lethargic. The features of black bile (Saudavi) variety are severe, grave and violent.

Usool-E-Ilaj (Principles of Treatment): Unani scholars also treated several bodily and mental ailments since ancient times by holistic approach through various modules of treatment viz; Ilaj-bil- Tadbeer (Regimenal therapy), Ilaj bil Ghiza (Dieto-therapy), Ilaj-bil- Dawa (Pharmacotherapy) and Ilaj-bil- Yad (Surgery).

• Evacuation of affected humours except for khilt-e- dam primarily through concoctives (munzijaat) followed by purgatives (mushilaat) for evacuation of morbid matters (tanqiya-e- mawaad) from the body, and secondarily venesection/ phlebotomy (fasd).
• Use of moisturizers (Murattib advia), alteratives of temperament (Moaddil-e- mizaj advia), massage therapy (dalk), exercise (riyazat) and mufarrehaat (exhilarants). These drugs and procedures relieve the tachycardia, palpitation and thirst and generally produce coldness.
• Use brain tonics (Muqawwi dimagh advia) and adoption of psychological measures (Nafsiyati tadabeer) are very helpful.

Ilaj (Treatment)

Melancholia is usually caused due to combustion of any of the four humours which ultimately converts to black variety (Saudavi), hence the affected humour i.e predominance of black bile (sauda) from the whole body has to be eliminated. Because it depends upon the body humour affected. 

• Venesection/ phlebotomy (Fasd) of saphenous or cephalic vein has to be performed to expel out the affected humour from the body till the blackish color and viscosity of flowing blood persists depending upon patient’s condition.
• Elimination of black bile (istafaragh-e- sauda) with the following Ma-ul- usool (medicated decoction of roots) of Khashkhash khushk (Papaver somniferum) Unnab (Zyziphus sativa), Sapistan (Cordia latifolia), Fuwah (Rubia cordifolia), Izkhar (Andopogams haenarthus), Post beekh kibr (Caparis spinosa root bark), Badyan (Foeniculum vulgare) each fistful, Mastagi (Pistacia lentiscus), Sunbuluttib (Nardostachis jatamansi root), Habbe zalam (Egyptian nut), Toodri (Lepidium iperis), Bozidaan (Pyrethrum indicum root), Asalsoos (Glycerrhiza glabra root), Barg-e- rehan (Ocimum sanctum), Barg badarnj boya (Mellisa officinalis), Gao’ zabaan (Borago officinalis), Maweez munaqqa (Vitis vinifera seed less fruit) each 25g, all drugs to be boiled and taken with Roghan badam sheerin (Prunus amygdalus) in a dose of 70ml for 7-10 days continuously, along with these Roghan banafsha (Viola odarata) should be applied over scalp and also inhaled through both nostrils.
• Tanqia with Jawarishaat made up of Haleela siya (Terminelia chebula unripe fruit), Aftimoon (Cuscuta reflexa), and Kundar (Boswellia serrata).
•  After fasd, measures to induce tarteeb (moistness) in the blood may be espoused through lamb’s meat cooked with Kaddu (Cucurbita maxima), palak (Spinacia olereacea), dressed with Roghan badam (Prunus amygdalus).
• Bai’ze neem barasht (half boiled egg yolk) with sharbate banafsha (Viola odorata).
• Habbe ustukhudoos (Lavandula stoechas) may be administered as purgative.
• If Istafaragh (evacuation) is essential, then Khaisanda (cantation) of Aftimoon (Cuscuta reflexa) and Ustukhudoos (Lavandula stoechas) with Maul jubn (Cow’s churned milk) to be given. Or istafaragh of Saudavi khilt through Joshande Aftimoon (Decoction of Cuscuta reflexa) mixed with Elwa (Aloe barbadensis) and Gharikhoon (Agaricus alba).
• Hammam (Turkish bath) with sweet water. Hammam-e- motadil with water consisting Banafsha (Viola odorata), Neelofer (Nelumbo nucifera), Bargkahu (Lactuca sativa), Barg-e- baboonah (Matricaria chamomile) and Post-e- khashkhaash (Papaver somniferum).
•  Aromatic flowers like banafsha (Viola odorata) or neelofer (Nelumbo nucifera) may be made to smell.
• Rest for three days followed by enema with chukhandar (Beet root), khatmi (Althea officinalis), wheat husk, laxative with Roghan banafsha (Viola odorata).
• Highly nutritious food is also recommended.
• Seb (Malus domestica) and Anar (Punica granatum) may be given.
• If condition persists above measures may be followed again.
• Moreover, aromatic oils like Roghan badam (Prunus amygdalus), Roghan kaddu (Cucurbita maxima), Roghan banafsha (Viola odorata) may be used as tadheen (unction) over the scalp to induce tarteeb.
• Sauda producing diet and drugs may be strictly avoided like dry meat, beef, meat of donkey, camel, swine, rabbit, jackal, brinjal, cabbage, masoor dal, baqala (Vicia faba), dates (Phoenix dactylfera), viscous and new wine, salty spicy foods.
• If affected maadda (matter) is less, body is dry and ghalbe dam is absent, then fasd and istafaragh should be avoided.
• Induce tarteeb in brain along with alteration in temperament and strengthening heart through exhilarants and cardiac tonics like Mushk (Moschcus moschiferus) and Anbar (Amber garacia).
• Saoot (inhale) with Roghan banafsha (Viola odorata), Roghan nilofer (Nelumbo nucifera), Roghan kaddu (Cucurbita maxima), and the same oils may also be used as massage over the scalp.
• Dawa-e- Mufarreh: Haleela kabli (Terminalia chebula) 5 nos, Gao’zabaan (Borago officinalis), Gulab (Rosa damascena), saad kofi (Cyperus rotundus) each 14g, Gha’ri khoon (Agaricus alba), Ustukhudoos (Lavandula
  stoechas) 10.5g, Mastagi (Pistacia lentiscus), Zafran (Crocus sativus), Rind of Turanj (Citrus modica), sunbul (Nardostachis jatamansi root), Asaroon (Valariana walichii root) each 10 g, Behmanain (Centaurea behen), Zaravand (Aristolochia longa), Ilaichi kalan (Amomum subulatum fruit), Nare Mushk (Mesua ferrea), Ood (Aquilaria agallocha), Zarnab (Taxus baccata), Tukhm-e- badaranj (Mellisa officinalis), Tukhm-e- faranjmushk (Ocimum gratissimum), Heel khurd (Elletaria cardamomum), sonf (Foeniculum vulgare), Barg-e- sonf (Foeniculum vulgare)leaves each 7g, Mushk (Moschcus moschiferus) 2.25g. All these drugs to be boiled in honey syrup in which Amla has been boiled.

Mujarrab Majoon (Effective Formulation)

Post-e- Halela siyah (bark of Terminelia chebula), Post-e- Halela kabuli (bark of Terminelia chebula), each 17.5g, Zarawand mudharaj (Aristolochia rotunda),  Zarawand Taweel (Aristolochia longa), Zaranbad (Curcuma zedoria), Waj Turki (Acorus calamus) each 14g, Kalonji (Nigella sativa), Hurmul (Peganum harmala) each 7g, Dar-e- Sheeshan (Myrica nagi), Juntiana Roomi (Gentiana lutea) each 5.25g, Bisfayij Fustaqi ((Polypodium vulgare) each 10.5g, Aftimoon (Cuscuta reflexa), Afsanteen (Artemisia absinthium) each 24.5 g, Irsa (Iris ensata) 17.5g, Buzr-ul- banj safed (Hyoscyamus albus) 4.66g, Kundush (Schoenocaulon officinale) 7 g, Ustukhudoos (Lavandula stoechas), Foowah (Rubia cordifolia), Tukhm-e- karafs (Apium graveolans), Anisoon (Pimpinella anisum), Badiyaan (Foeniculum vulgare), Gharikhoon safed (Agaricus alba) 10.5g, Turbud safed mujawwaf (Operculina turpenthum) 14g, Qaranfal (Caryophyllus aromaticum), Taj (Cinnamomum cassia) 10.5g, Sibr Saqootari (Aloe barbedensis) 35g, Mastagi Roomi (Pistacia lentiscus) 10.5g, Kharbaq mudabbar (Helleborus niger) 17.5g, Gao zabaan (Borago officinalis), Barg-e- badaranjaboya (Mellisa officinalis), Barg-e- faranjmushk (Ocimum gratisimum) 14g, Zafraan (Crocus sativus) 5.25g-

This semi solid preparation (Majoon) is to be prepared with above mentioned ingredients and given in a dose of 15.75g every 10^th day.

During this medication Roghan-e- banafsha (Oil of Viola odorata) be massaged over the body and instilled in nostrils and also apply over scalp.

Hijamat Naariya (fire cupping) over head and light exercises are also recommended in this case.

Itreefal sagheer, Aftimoon, Iyaerij feeqra, Majoon najah, and Majoon mufarreh are also found to be very effective.

Habbe Iyaarij, Joshanda aftimoon, Iyaarij Jalinoos, Habb-e- aftimoon, Turanjabeen and Jawarish Jalinoos is also recommended.

If melancholia is caused due to intense heat

In this condition temperament of brain (Mizaaj-e- dimaagh) may be restored/ normalised by inducing moistness. Head of the affected person to be soaked in moist oils and cold and moist diet maybe advised. Similarly boiled water (In which some Unani/ herbal drugs may be boiled) may be poured over scalp. These drugs consist of Nelumbo nucifera (Neelofer), Viola odorata Linn. (Banafsha), Papaver somniferum Linn. (Post-e- Khashkhaash), Rind of Cucurbita maxima (Kaddu ka chhilka) and Belladona atropa (Beekh-e- yabrooj).

If melancholia is caused due to involvement of peritoneum, stomach or spleen

• If black bile (sauda) is accumulated in stomach, peritoneum or spleen, then vomiting may be induced and its evacuation should be done by Cuscuta reflexa (Aftimoon) and Sikanjabeen.
• Fanjnosh with Jawarish Ood and Jawarish Safarjal for evacuation super added with Elwa (Aloe barbadensis Linn.) and Aftimoon (Cuscuta reflexa Linn.) is very effective.
• Aloe barbedensis (Elwa) as a single drug is also very effective
• Artemisia absinthium (Afsanteen) 2.25 g with water is found to be very beneficial.
• Vinegar of wild onion (Jangli Piyaz ka sirka) to be sipped for quick relief.
• Diet such as kadu, pathreli machli, cold and moist vegetables like Kasni, Khas, Palak and Bathwa is also beneficial.
• Highly nutritious and easily digestible diet is recommended.
• Saoot (Inhaler): Take Kafoor 0.5 part, Zafran 1 part, Mix well both the drugs with mother’s milk and instill in nostrils.
• Nutool (Douching): Douching with medicated decoction of Shibat, Suddab, Podina, Funjkhusht, Afsanteen and Habb-ul- ghaar is also recommended.
• Hijaamah (Cupping): Cupping over spleen or stomach is such cases is very beneficial
• Dalak (Massage): Massage of Roghan-e- sosan over abdomen is also advised.

Psychological Measures (Nafsiyaati Tadaabeer): The measures are very beneficial if applied to the patient of melancholia (Malamkholia)

• Entertainment with melodious songs and music, sports activities, engagement in humorous sittings is highly recommended for such patients.
• Loneliness, suspicious thinking etc. very is harmful and it must be avoided.
• Abrupt emotional incidents relieve the patients from melancholia (Malankholia) sometimes.
• Beautiful and heart rending scenery and activities to be promoted in the habitat of the patient.
• Prolong studying habits, prolong wakefulness, excessive mental pondering may also lead to pseudo melancholia.
• These factors enable the combustion of body humours (akhlat) leading to irritability (Hizyaan).
• This type of melancholy is treated with moistness (Tarteeb), resolution (Tahleel), detoxification (Tanqia) and nutrition (Taghziya).

To sum up the management approach, the following do’s and dont’s are summarized below for easy understanding and healthy approach:

Do’s:

• Eliminating black bile (sauda) from body is very important.
• The atmospheric air surrounding the habitat of the patient should be made moist (Murattab) and fragrant flowers or aroma should be spreaded there.
• Dress and bedsheet of the patient should be particularly white in colour.
• Moist (murattib) and exhilarant (mufarreh) perfumes and aromas should be administered in the form of inhalation (Lakhlakha).
• Exhilarant (mufarreh), moist (murattib), blood purifier (mussafi-e- khoon) and highly nutritious diet must be served to the patients.
• Strengthening the body with adequate food / nutrition is very important.
• Keeping the patient busy with entertainment with playing, singing etc also benefits.
• Allow the patient to have a moderate medicated bath (Hammam), pouring luke warm water over the head before administering meal is very useful.
• For inducing sleep; Nutool (douching) with Khashkhaash (Poppy seeds), Baboonah (Matricaria chamomile) is recommended.
• Much importance should be given on Tarteeb (moisture) over Taskheen (calorificient); therefore, Maul Jubn (cow’s churned milk) is considered as a good mubarrid (refrigent).
• Similarly pouring milk over the scalp (head), local application (Tila) of luke warm chicken fat (murgh ki charbi) are good refrigents.

Don’ts:

• Vigorous activities and excessive sexual intercourse must be avoided
• Huzn wa Malal (Mourning and affliction) and Fikr (Thought /Thinking) and  Ghazab/ Ghussa (Rage) must be avoided
• Dark and congested inhabitation is very harmful
• Wearing black cloths (Kale kapde pahnna), other things with black colour must be avoided. Similarly peeping towards darkness must be avoided.
• Camel meat, cow meat, hilly and desert and animal’s meat must be avoided.
• Big fishes (Giant fishes) are also need to be avoided.
• Karam kalla (cabbage), Masoor, Baigan (brinjal), Baqla, mustard leaves, Gandana, Mustard, Garlic, Onion, Dried mutton, New and Viscous alcohol (beverage- Sharab) and other such melanogouge items must be avoided.
• Salty and sour items must be avoided.
• Namak-e- siyah, Dried Cheese, Mooli (radish) and Ghee are also to be avoided
• Temperamentally hot or cold things and diet need to be avoided.
• Bhoosi wali rooti (Fibrous bread) is also harmful and need to be avoided.
• Very limited use is advisable for sweet, tasteless and spicy items.
• Unseeded Tukhm-e- Khurfa (Apeum graveolens linn.) is also not recommened.
• Sleeplessness, excessive thinking, loneliness, hard work, hunger and thirst are all injurious and must be avoided, similarly the things which will produce or increase dryness and hotness in the body and brain.

References

https://www.omicsonline.com/open-access/an-insight-on-malankholia-melancholiaunani-perspective-2378-5756-1000327.php?aid=62957

http://www.greekmedicine.net/Principles_of_Treatment/Managing_the_Melancholic_Temperament.html

http://www.journalagent.com/ias/pdfs/IAS_23_4_140_146.pdf

http://mdsaoodalamunanimedicine.blogspot.co.uk/2014/03/melancholia.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217817/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252723/

Note:

• Along with medicine the patients have to follow strict regimen as per the concept of Unani system. The patients are therefore, strongly advised to avoid self-medication.
• They are advised to visit the nearest authorized Unani treatment centre or any regional or central research institute of CCRUM (Central Council for research In Unani Medicine) for advice and treatment.