importance. In the very earliest stage quiet, recreation, change of
scene, and association with a pleasant and judicious companion are
often sufficient to effect a cure. If the disease is pronounced, rest
and removal from sources of irritation are more important until
convalescence, when travel may be tried. The question of removal from
home and commitment to an asylum {160} should be decided upon the
grounds already stated in considering the general treatment of mental
diseases. The degree in which the patient should have exercise,
occupation, and recreation or be let alone will be determined for each
individual case. The fact should be borne in mind that the disease is
a debilitating one, and that it arises in conditions of mental or
physical exhaustion. Massage and a modified rest-cure, without
seclusion, are beneficial in some cases, especially of elderly people.
Baths and the cold pack should be used with discrimination.
Electricity, where it does not give rise or add to delusions, is a
useful tonic, especially in passive cases. There are very few patients
of such desperate frenzy as to require confinement of the hands, and
that should only be done with an attendant close at hand. Whatever is
done, nothing should be attempted which excites delusions unless it be
absolutely necessary. Fresh air, and an abundance of it, are very
important. Experience and careful study of the particular case will be
needed to know how far to press the taking of food. But the necessary
amount should be given by the stomach-tube if ordinary means fail, and
it is better to use it early rather than tire the patient out with
ineffectual attempts with spoons, etc. Whether the nasal or œsophageal
tube be used—of which I prefer the latter—the greatest care should be
taken not to inject food into the lungs, the throat being so devoid of
sensitiveness sometimes that the tube may be passed into the trachea.
Nutrient enemata may be relied upon for a week or two if the patient
is in bed, but no longer.
Tonics are indicated—cod-liver oil with bark, the hypophosphites,
dilute phosphoric acid, malt. Strychnia, iron, and quinine should be
used with caution, as they often cause disagreeable headache with
indisposition to sleep. Fattening food will be found useful in most
cases. The few fat melancholies need nitrogenous food and graduated
exercise. Constipation will be corrected in many cases by a full,
laxative diet, cod-liver oil, malt, or it may be beer. Mineral water
or Sprudel salts are usually indicated. A pill containing aloin,
strychnia, belladonna, mastich, or even colocynth or podophyllin, may
be needed in obstinate constipation.
Medicines to control restlessness and sleeplessness should be avoided
if possible. Hydrate of chloral, opium, bromides, valerian, sometimes
increase the difficulty, and the objections to their prolonged use are
obvious, and yet they must sometimes be used for a time. The bromides,
with cannabis indica, valerianate of zinc, camphor, and hyoscyamus,
may serve an excellent purpose for a time. Opium and its preparations,
where they agree, act like magic in producing mental calm and sleep.
They may relieve constipation and increase the desire for food, but
the danger of the opium habit is so great that their use should be
decided upon only in extreme cases, and the effect should be watched
from dose to dose, each one of which should be given under medical
direction. Wilful masturbation, one of the signs of loss of
self-control which occurs in the best of people, cannot be corrected
by drugs or appliances, but only by constant watching and by placing
the individual where his self-respect, as soon as it can be appealed
to, will keep him from it. If it is uncontrollable and symptomatic,
fresh air and exercise, and, if necessary, bromides or opiates in
moderate doses, with a tonic (not iron), should be used.
{161} MANIA (Manie, Exaltation générale), according to Morel, meant,
in the original Greek, folie or madness, while Esquirol derives it
from the Greek word meaning moon, making the words maniac and lunatic
equivalent. The word mania is still used in this loose way, even by
writers on mental disease, as a synonym of insanity. Its use is
properly restricted to conditions of mental exhilaration or excitement
with motor activity. The morbid anatomy of the disease is not yet made
out, and the indications of hyperæmia observed in the acute stage
after death are no greater than are found in diseases in which mania
is not a symptom. In its final stages atrophic, degenerative, and
inflammatory signs are abundant and well marked.
Simple mania[18] (manie sans délire, manie raisonnante), an exaltation
of the mental faculties similar to the exhilaration produced by too
much wine, with an accelerated flow of ideas, impaired judgment, and
motor activity, without definite delusions, delirium, or incoherence,
has been called an insanity of action, affective insanity, folie
raisonnante, and even moral insanity, from which it differs in being
marked by constant mental elation and exaltation of the physical
functions, and not necessarily by striking moral perversion. It is a
mental erethism, an exaggerated gayety, an uncontrollable
exhilaration, an unbounded joy, an excessive anxiety, a perpetual
anger, unusually good spirits, increased intellectual and physical
energy, with such striking loss of self-control, diminished powers of
reflection, and so decided weakening of the judgment that all sorts of
unwonted errors of commission or omission may be performed. Under its
influence many fortunes have been lost, many reputations have been
ruined, and the happiness of many families has been sacrificed before
the existence of insanity was suspected, except possibly by a very few
persons. Indeed, the wit is usually so sharpened, the flow of ideas
often so clear and rapid, the capacity for brain- and body-work
without fatigue is generally so increased, that not seldom the patient
is remarked upon as being unusually well. The most troublesome
symptoms arise from the tendency to squander property, to drink
alcoholic liquors to excess, and, especially in women, to allow the
exalted sexual desires to get control of the judgment and reason,
thereby bringing about unfortunate marriages or scandalous relations
with the opposite sex. In women there is commonly increased menstrual
flow.
[Footnote 18: Also called by some writers moral insanity, folie
morale, folie des actes, folie or manie instinctive.]
The course of the disease is without material change, and the duration
is from several weeks to a number of years. When it does not
constitute the initial stage of other types of mental disease,
especially severer forms of mania, circular insanity, general
paralysis, or (in the neuropathic constitutions and at the critical
ages) mental degeneration, the termination is in recovery in about 90
per cent. of the cases, although sometimes some moral impairment or
deterioration in character remains for life. The recklessness incident
to the disease leads to unusual risks, now and then to fatal
accidents. Simple mania rarely becomes chronic.
TREATMENT involves the necessity of proper control to prevent
scandals, disasters, and perhaps crimes. The matter of the degree of
seclusion and control should be governed by the general considerations
already mentioned in the general treatment of insanity, bearing in
mind that {162} repression of the motor energy, except to prevent
exhaustion, does harm. The demand for food is enormous; its supply
should be abundant and judiciously chosen with reference to easy
digestion. Frequent prolonged warm baths and cool applications to the
head are indicated, and the usual palliatives for headache,
sleeplessness, constipation, etc. The surroundings should be such as
to favor rest and undisturbed sleep, and to dispel sources of
excitement, whether they arise in certain associations, localities,
occupations, or persons.
Acute mania (Tobsucht) follows an incubative stage of simple
melancholia, often of simple mania, and rarely bursts out without
previous indications of disease. Delusions, unsystematized and
illogical, are abundant; the ideas flow so rapidly that the mechanism
of speech is not adequate to their expression; the motor excitement is
intense. In the most severe forms there is mental confusion, delirium,
incoherence of ideas, and furious muscular action, to the point often
of acts of destructiveness and self-injury. The clothing is torn to
shreds, and no act of violence is too wild not to be attempted without
warning. The skin is hot, the tongue heavily coated, the pulse
accelerated, the temperature elevated, more, probably, than would be
accounted for by the physical activity—from one to two or three
degrees—now and then, in conditions of exhaustion, a little below the
normal. Just as there is liable to be maniacal frenzy in the course of
severe melancholia, so in acute mania outbursts are seen of
desperately suicidal melancholic frenzy. Unless great care is used to
keep up the strength, and often in spite of it, exhaustion rapidly
sets in, under the influence of which the symptoms are very much
aggravated. The amenorrhœa in women in this condition is conservative.
The COURSE AND DURATION of acute mania vary within wide limits, with
an average of not far from six months, with recoveries in about 60 per
cent. of first cases uncomplicated by pneumonia, chronic disease, or a
marked neuropathic state: 5 or 6 per cent. die, chiefly from
pneumonia, phthisis, accidents, or exhaustion, seldom suicide.
Incurable cases drop slowly into dementia or into chronic delusional
insanity, the motor excitement subsiding. The delusional insanity may
be simply a stage in the process toward dementia.
In the DIAGNOSIS of acute mania, unless great care is used, the
physician sometimes finds that he has sent to the asylum a case of
acute, especially infectious disease, in the early stage and with
unusual manifestations of febrile delirium. The indications for
avoiding this unfortunate mistake are care and time in making
diagnoses.
In the TREATMENT of acute mania the matter of foremost importance is
that the physician should be able to sufficiently control his patient
to prevent harm, and that he should have him in such a place as to
give him an abundance of fresh air, unhampered by annoying and
irritating limitations of his free will, restrictions of his liberty,
and repression of his motor excitement. The risks of injury to others
must be reasonably provided against. It goes without saying that few
homes meet these indications: very few people can command a house to
be converted into a virtual hospital, with the care of trained
physicians to direct every little detail of treatment, and proper
nursing. The public asylum, therefore, or the private retreat must
usually be depended upon. In the case {163} of quiet young people,
especially of young women whose illness may be of such a nature as to
justify their marrying after recovery, and in the acute mania
following childbirth, it is well worth the physician's while to make
an effort to keep the patient in a private house when the conditions
are such as to make such a course practicable. To the rest and quiet
which may be had under such circumstances, with all the goings on of
the house regulated to the patient's comfort and convenience, to
prolonged hot baths, a full simple diet, given with the stomach-tube
if necessary, as few medicines as can be got on with, the supervision
of the nurses by some judicious member of the family, and the
gentleness (combined, of course, with proper firmness) of
home-influences, I attach very great importance in properly selected
cases. But I attribute as much to the restful influence of keeping the
patients among familiar scenes, and where some familiar face and voice
can reassure them in their comparatively clear moments, instead of
their being agitated and distressed to know how to account for the
strange people and cell-like room of the insane ward to which they
will awaken from their delirium in the hospital. It is something to
avoid the excitement of commitment and removal to an asylum, with all
that they involve, as well as the sight of demented patients, whose
noise may make sleep impossible just when it is most needed. Acute
mania seems to me to arise much less often than other mental diseases
in definite associations which need to be escaped from for successful
treatment.
The term subacute mania is used by some writers for the milder cases
of acute mania, just as acute delirious mania is a term which is
applied to those violent cases of acute mania in which furious and
prolonged delirium marks the disease, and in which there is a high
death-rate and low proportion of recoveries.
In chronic mania the motor excitement, mental instability, and, sooner
or later, delusions, if not present at the beginning, as is usual,
continue. The progress to dementia is commonly slow, and there are few
cases which it is wise to treat away from an asylum or its
dependencies on account of the possible danger to others from sudden
exacerbations of the disease or through uncontrolled violent impulses.
Although there is no pathological condition distinctive of mania in
its curable stage, conditions indicating hyperæmia are usually found,
whether as a result of the disease or its underlying cause, and
sometimes meningitis. In chronic mania there is in the terminal stages
evidence of atrophic and degenerative changes which do not distinguish
it from other forms of mental disease.
ACUTE DELIRIUM is the typhomania of Bell. Its prevailing mental state
is of mania oftener than of melancholia. It resembles the worst cases
of typhoid fever so closely, and it is so uncommon a form of disease,
that the mistake has often been made of sending typhoid-fever patients
to insane asylums. The mistake is unnecessary, as the clinical
features of typhoid fever are so well marked that with sufficient care
and delay they may be recognized if the physician does not commit the
common error in mania of being too much afraid of his patient to
examine him thoroughly. The tendency to exhaustion in acute delirium
is rarely successfully combated, as the motor excitement is so intense
and the delirium so furious that nourishment to meet the tremendous
demands of the {164} system can seldom be given, and death is the
usual result. Recoveries are rare, but less uncommon in the
melancholic than in the maniacal form.
Little need be said in the way of TREATMENT, except that in so
speedily fatal a disease it is well to keep the patient at home, if he
can be properly cared for there.
TRANSITORY INSANITY is used by Krafft-Ebing[19] (Transitorisches
Irresein) as indicating mental disease differing from other insanity
only in the fact that it is of short duration—namely, from two to six
days. If it is applied to sudden and transient outbursts of mania,
with delirium, loss of power of self-control, and inability to clearly
recollect the circumstances of the attack and what happened during its
continuance, it is a rare disease, occurring for the most part in
epileptics and in persons under the influence of alcohol or addicted
to its habitual use. It is sometimes, under the latter-named
condition, called alcoholic trance. It consists in an automatic state
resembling the epileptic delirium, which may occur also in sleep and
resemble somnambulism. The actions are guided by co-ordinated will
without conscious intelligence, and may consist in crimes and
brutalities and foolishness entirely inconsistent with the character
in health. It seldom lasts more than a few hours. When caused by
alcohol or as a symptom of epilepsy, it may occur without other marked
inciting cause; otherwise it is commonly due to mental shock. Several
cases happened during the mental excitement of the first battle in our
civil war. The most striking case within my own experience was that of
a man who under the strain of prolonged grief and the mental shock of
a great fire destroying a large part of the town in which he lived,
perhaps moderately affected by alcohol, suddenly grasped an axe and
cut off with one blow the head of a beloved child. He was found in the
street without knowing how he had got there or what he had done.
[Footnote 19: _Irrenfreund_, 1883, p. 113.]
One attack is the rule, although several, probably of an epileptic
nature, have been reported. It is an extremely difficult condition to
diagnosticate with certainty, and is therefore often the refuge of
criminals and a resource of criminal lawyers. The most likely honest
mistake liable to be made regarding it is to confound it with an
outburst of passion.
PRIMARY DEMENTIA (Acute dementia, Stuporous insanity, Anergic stupor)
is a disease chiefly of youth and early maturity in persons of
inherited weakness or under the influence of prolonged exhausting
conditions, to which some mental shock usually adds the immediate
cause. Although most of the cases are under the age of twenty-five, it
occurs up to forty-five. Masturbation is so common a symptom in its
course—and it may be one of the debilitating and enervating factors
constituting a predisposing cause—that most of the primary dementia is
classed in some asylums as insanity of masturbation. There may be an
initial stage of a number of days, marked by moderate melancholia or
by maniacal excitement, but there is usually mental torpor advancing
rapidly to pronounced dementia. In rare cases there is marked chorea,
and slight choreic movements are often observed. The course of primary
dementia may be subacute and advance with extreme slowness.
There is no overwhelming delusion paralyzing the mind, so to speak, as
in melancholia attonita (melancholia with stupor). In acute cases the
brain quickly falls into a state of profound anæmia, precisely such as
is {165} found post-mortem in starved dogs, and loses its power to a
greater or less extent of reacting to the stimulus of the senses.
There is little or no sensation of hunger, the sensory nerves are
nearly or quite paralyzed, the bladder and rectum become distended
until urine and feces are voided unconsciously or at least
uncontrolled, and voluntary movements almost cease, although the
muscles are capable of acting if directed: if led or pushed, the
patient walks; if placed in a chair or bed, remains there; and in the
worst cases lies on the floor quite inattentive to all the decencies
of life unless constantly looked after. There is always partial, and
there may be complete, anæsthesia, to such an extent that even the
involuntary muscles do not respond to the ordinary stimuli. There is
rapid loss of flesh, very sluggish circulation, and feeble
heart-action. After recovery the patient speaks of the stage of his
greatest illness as a blank in his memory.
This description of pronounced cases of primary dementia of the most
severe type needs modification as applied to milder cases, which may
exist in all degrees, down to a state of mental impairment of very
moderate extent.
The mental impairment may be progressive and quite incurable, but also
so slight in the beginning, and may make such slow progress, as to
entirely escape detection for several years, and then attract
attention at first by the lowered plane of character and loss of
self-control in little matters of daily life, rather than by the
intellectual deterioration, which by that time has become quite
marked. This subacute form of primary dementia in young people rarely
finds its way into the insane asylum until the second, third, or
fourth year of its course, and then its progress is slowly downward.
It has none of the eccentric or grotesque features of hebephrenia, and
little of its emotional disturbances.
Subacute primary dementia in the later years of maturity, just before
or several years before the climacteric, is of grave import, as it
indicates the development of an hereditary predisposition to insanity
in a form which not only offers no reasonable hope of recovery, but
also is quite certain to manifest a change of character which is even
more difficult to treat and properly control than the intellectual
failure. As it is most likely to arise under circumstances of wear and
worry, its symptoms may be for a long time attributed to
disappointment or bad temper. After the dementia becomes pronounced
its downward course is seldom otherwise than very rapid.
SECONDARY DEMENTIA is a convenient name for the curable dementia which
appears at the subsidence of acute symptoms occasionally in mania, and
rarely in melancholia—that is, just about the beginning of the period
of convalescence. It is also called secondary stupor.
In primary and secondary dementia, resulting in recovery, the progress
of the disease is rarely otherwise than very rapid, and unless a cure
takes place in a few months at the outside, secondary changes occur in
the brain and the tendency is to terminal or incurable dementia. So
many cases are treated outside of asylums that it is difficult to
estimate the cure-rate, but it is probably not less than 60 or 70 per
cent., although it is quite common in the apparent cures for the brain
to remain on a lower intellectual or moral plane than if the disease
had not occurred.
TREATMENT does not involve the necessity of removal from home in {166}
the acute cases, except when that is demanded for convenience of
treatment. There is no melancholia to suggest the possibility of
suicide, and no mental exhilaration or motor excitement to make
restraint necessary. The most important indications are met by
abundant, easily-assimilated food, which must usually, for a time at
least, be given with a spoon or by the stomach-tube; fresh air,
attention to the processes of digestion, relief of the
gastro-intestinal catarrh by the usual remedies, stimulating baths,
tonics, stimulants, and general galvanism. Proper care in emptying the
bladder and rectum and entire cleanliness will suggest themselves.
In mild cases a tonic and stimulating regimen, including sea-bathing
and gymnastics, will often be sufficient.
In the subacute cases young people are easily depressed by the asylum
associations, but there is usually a time in the progress of the
disease when home-discipline is too weak for them, and they must be
sent away; older people have usually complications in their home-life
such as to make a change desirable for the comfort of the household.
Recoveries are extremely exceptional.
In all cases there is little to be gained in keeping up
home-associations for so disturbing, distressing a disease after there
is pronounced dementia.
Medicines, other than tonics, are of little use, except opiates to
control various distressing nervous symptoms, including masturbation,
but they should be used with great caution.
KATATONIA (Katatonie of Kahlbaum; Katatonische Verrücktheit of Schüle)
presents, with more or less regularity of appearance, symptoms of (1)
mild melancholia without the characteristic mental pain; (2) mental
excitation, sometimes ecstatic, with cataleptiform conditions; (3)
confusion and torpor or apathy. There is an underlying well-marked
intellectual impairment, slowly advancing in incurable cases to
pronounced dementia. Delusions, more of the unsystematized than of the
systematized character, but resembling both, constitute a prominent
part of the disease from the beginning. Verbigeration and a curious
sort of pomposity are usually found in more or less pronounced degree.
The delusions are mixed. They are exalted, hypochondriacal,
melancholic, with all sorts of self-accusation, and may be full of
suspicion, fears of poisoning, and ideas of persecution.
Hallucinations of the special senses and illusions are not uncommon.
If the term katatonia is not used, or at least if a special place in
the nosology were not given this disease, it would be difficult to
know whether to class these cases as primary dementia, melancholia
with delusions, delusional insanity, or confusional insanity.