Melancholia.Mania.Delusional Insanity.Katatonia.Hebephrenia.Traumatic Insanity.Insanity following upon arterial degeneration.Insanities associated or caused by: General Paralysis; Epilepsy.Insanities associated with or caused by Alcoholic and Drug intoxication: Delirium Tremens, Chronic Alcoholic Insanity, Dipsomania, Morphinism.Senile Insanity.
Melancholia.
Mania.
Delusional Insanity.
Katatonia.
Hebephrenia.
Traumatic Insanity.
Insanity following upon arterial degeneration.
Insanities associated or caused by: General Paralysis; Epilepsy.
Insanities associated with or caused by Alcoholic and Drug intoxication: Delirium Tremens, Chronic Alcoholic Insanity, Dipsomania, Morphinism.
Senile Insanity.
The general symptoms of acquired insanity group themselves naturally under two heads, the physical and the mental.
The physical symptoms of mental disease generally, if not invariably, precede the onset of the mental symptoms, and the patient may complain of indefinite symptoms of malaise for weeks and months before it is suspectedGeneral symptoms.that the disorder is about to terminate in mental symptoms. The most general physical disorder common to the onset of all the insanities is the failure of nutrition,i.e.the patient rapidly and apparently without any apparent cause loses weight. Associated with this nutritional failure it is usual to have disturbances of the alimentary tract, such as loss of appetite, dyspepsia and obstinate constipation. During the prodromal stage of such conditions as mania and melancholia the digestive functions of the stomach and intestine are almost or completely in abeyance. To this implication of other systems consequent on impairment of the trophesial (nourishment-regulating) function of the brain can be traced a large number of the errors which exist as to the causation of idiopathic melancholia and mania. Very frequently this secondary condition is set down as the primary cause; the insanity is referred to derangements of the stomach or bowels, when in fact these are, concomitantly with the mental disturbance, results of the cerebral mischief. Doubtless these functional derangements exercise considerable influence on the progress of the case by assisting to deprave the general economy, and by producing depressing sensations in the region of the stomach. To them may probably be attributed, together with the apprehension of impending insanity, that phase of the disease spoken of by the older writers as thestadium melancholicum, which so frequently presents itself in incipient cases.
The skin and its appendages—the hair and the nails—suffer in the general disorder of nutrition which accompanies all insanities. The skin may be abnormally dry and scurfy or moist and offensive. In acute insanities rashes are not uncommon, and in chronic conditions, especially conditions of depression, crops of papules occur on the face, chest and shoulders. The hair is generally dry, loses its lustre and becomes brittle. The nails become deformed and may exhibit either excessive and irregular or diminished growth.
Where there are grave nutritional disorders it is to be expected that the chief excretions of the body should show departures from the state of health. In this article it is impossible to treat this subject fully, but it may suffice to say that in many states of depression there is a great deficiency in the excretion of the solids of the urine, particularly the nitrogenous waste products of the body; while in conditions of excitement there is an excessive output of the nitrogenous waste products. It has lately been pointed out that in many forms of insanity indoxyl is present in the urine, a substance only present when putrefactive processes are taking place in the intestinal tract.
The nervous system, both on the sensory and motor side, suffers very generally in all conditions of insanity. On the sensory side the special senses are most liable to disorder of their function, whereby false sense impressions arise which the patient from impairment of judgment is unable to correct, and hence arise the psychical symptoms known as hallucinations and delusions. Common sensibility is generally impaired.
On the motor side, impairment of the muscular power is present in many cases of depression and in all cases of dementia. The incontinence of urine so frequently seen in dementia and in acute insanity complicated with the mental symptom of confusion depends partly on impairment of muscular power and partly on disorder of the sensory apparatus of the brain and spinal cord.
The outstanding mental symptom in nearly all insanities, acute and recent or chronic, is the failure of the capacity of judgment and loss of self-control. In early acute insanities, however, the two chief symptoms which are most evident and easily noted are depression on the one hand and excitement or elevation on the other. Some distinction ought to be made between these two terms, excitement and elevation, which at present are used synonymously. Excitement is a mental state which may be and generally is associated with confusion and mental impairment, while elevation is an exaltation of the mental faculties, a condition in which there is no mental confusion, but rather an unrestrained and rapid succession of fleeting mental processes.
The symptoms which most strongly appeal to the lay mind as conclusive evidence of mental disorder are hallucinations and delusions. Hallucinations are false sense impressions which occur without normal stimuli. The presence of hallucinations certainly indicates some functional disorder of the higher brain centres, but is not an evidence of insanity so long as the sufferer recognizes that the hallucinations are false sense impressions. So soon, however, as conduct is influenced by hallucinations, then the boundary line between sanity on the one hand and insanity on the other has been crossed. The most common hallucinations are those of sight and hearing.Delusions are not infrequently the result of hallucinations. If the hallucinations of a melancholic patient consist in hearing voices which make accusatory statements, delusions of sin and unworthiness frequently follow. Hallucinations of the senses of taste and smell are almost invariably associated with the delusion that the patient’s food is being poisoned or that it consists of objectionable matter. On the other hand, many delusions are apparently the outcome of the patient’s mental state. They may be pleasant or disagreeable according as the condition is one of elevation or depression. The intensity and quality of the delusions are largely influenced by the intelligence and education of the patient. An educated man, for instance, who suffers from sensory disturbances is much more ingenious in his explanations as to how these sensory disturbances result from electricity, marconigrams, X-rays, &c., which he believes are used by his enemies to annoy him, than an ignorant man suffering from the same abnormal sensations. Loss of self-control is characteristic of all forms of insanity. Normal self-control is so much a matter of race, age, the state of health, moral and physical upbringing, that it is impossible to lay down any law whereby this mental quality can be gauged, or to determine when deficiency has passed from a normal to an abnormal state. In many cases of insanity there is no difficulty in appreciating the pathological nature of the deficiency, but there are others in which the conduct is otherwise so rational that one is apt to attribute the deficiency to physiological rather than to pathological causes. Perversion of the moral sense is common to all the insanities, but is often the only symptom to be noticed in cases of imbecility and idiocy, and it as a rule may be the earliest symptom noticed in the early stages of the excitement of manic-depressive insanity and general paralysis.The tendency to commit suicide, which is so common among the insane and those predisposed to insanity, is especially prevalent in patients who suffer from depression, sleeplessness and delusions of persecution. Suicidal acts may be divided into accidental, impulsive and premeditated. The accidental suicides occur in patients who are partially or totally unconscious of their surroundings, and are generally the result of terrifying hallucinations, to escapefrom which the patient jumps through a window or runs blindly into water or some other danger. Impulsive suicides may be prompted by suddenly presented opportunities or means of self-destruction, such as the sight of water, fire, a knife, cord or poison. Premeditated suicides most frequently occur in states of long continued depression. Such patients frequently devote their attention to only one method of destruction and fail to avail themselves of others equally practicable. As a rule the more educated the patient, the more ingenious and varied are the methods adopted to attain the desired result.The faculty of attention is variously affected in the subjects of insanity. In some the attention is entirely subjective, being occupied by sensations of misery, depression or sensory disturbances. In others the attention is objective, and attracted by every accidental sound or movement. In most of the early acute insanities the capacity of attention is wholly abolished, while in hebephrenia the stage of exhaustion which follows acute excitement, and the condition known as secondary dementia, loss of the power of attention is one of the most prominent symptoms. The memory for both recent and remote events is impaired or abolished in all acute insanities which are characterized by confusion and loss or impairment of consciousness. In the excited stage of manic-depressive insanity it is not uncommon to find that the memory is abnormally active. Loss of memory for recent but not remote events is characteristic of chronic alcoholism and senility and even the early stage of general paralysis.Of all the functions of the brain that of sleep is the most liable to disorder in the insane. Sleeplessness is the earliest symptom in the onset of insanity; it is universally present in all the acute forms, and the return of natural sleep is generally the first symptom of recovery. The causes of sleeplessness are very numerous, but in the majority of acute cases the sleeplessness is due to a state of toxaemia. The toxins act either directly on the brain cells producing a state of irritability incompatible with sleep, or indirectly, producing physical symptoms which of themselves alone are capable of preventing the condition of sleep. These symptoms are high arterial tension and a rapid pulse-rate. The arterial tension of health ranges between 110 and 120 millimetres of mercury, and when sleep occurs the arterial tension falls and is rarely above 100 millimetres. In observations conducted by Bruce (Scottish Medical and Surgical Journal, August 1900) on cases of insanity suffering from sleeplessness the arterial tension was found to be as high as 140 and 150 millimetres. When such sleep was obtained the tension always sank at once to 110 millimetres or even lower. In a few cases suffering from sleeplessness the arterial tension was found to be below 100 millimetres, accompanied by a rapid pulse-rate. When sleep set in, in these cases, no alteration was noted in the arterial tension, but the pulse was markedly diminished.
The symptoms which most strongly appeal to the lay mind as conclusive evidence of mental disorder are hallucinations and delusions. Hallucinations are false sense impressions which occur without normal stimuli. The presence of hallucinations certainly indicates some functional disorder of the higher brain centres, but is not an evidence of insanity so long as the sufferer recognizes that the hallucinations are false sense impressions. So soon, however, as conduct is influenced by hallucinations, then the boundary line between sanity on the one hand and insanity on the other has been crossed. The most common hallucinations are those of sight and hearing.
Delusions are not infrequently the result of hallucinations. If the hallucinations of a melancholic patient consist in hearing voices which make accusatory statements, delusions of sin and unworthiness frequently follow. Hallucinations of the senses of taste and smell are almost invariably associated with the delusion that the patient’s food is being poisoned or that it consists of objectionable matter. On the other hand, many delusions are apparently the outcome of the patient’s mental state. They may be pleasant or disagreeable according as the condition is one of elevation or depression. The intensity and quality of the delusions are largely influenced by the intelligence and education of the patient. An educated man, for instance, who suffers from sensory disturbances is much more ingenious in his explanations as to how these sensory disturbances result from electricity, marconigrams, X-rays, &c., which he believes are used by his enemies to annoy him, than an ignorant man suffering from the same abnormal sensations. Loss of self-control is characteristic of all forms of insanity. Normal self-control is so much a matter of race, age, the state of health, moral and physical upbringing, that it is impossible to lay down any law whereby this mental quality can be gauged, or to determine when deficiency has passed from a normal to an abnormal state. In many cases of insanity there is no difficulty in appreciating the pathological nature of the deficiency, but there are others in which the conduct is otherwise so rational that one is apt to attribute the deficiency to physiological rather than to pathological causes. Perversion of the moral sense is common to all the insanities, but is often the only symptom to be noticed in cases of imbecility and idiocy, and it as a rule may be the earliest symptom noticed in the early stages of the excitement of manic-depressive insanity and general paralysis.
The tendency to commit suicide, which is so common among the insane and those predisposed to insanity, is especially prevalent in patients who suffer from depression, sleeplessness and delusions of persecution. Suicidal acts may be divided into accidental, impulsive and premeditated. The accidental suicides occur in patients who are partially or totally unconscious of their surroundings, and are generally the result of terrifying hallucinations, to escapefrom which the patient jumps through a window or runs blindly into water or some other danger. Impulsive suicides may be prompted by suddenly presented opportunities or means of self-destruction, such as the sight of water, fire, a knife, cord or poison. Premeditated suicides most frequently occur in states of long continued depression. Such patients frequently devote their attention to only one method of destruction and fail to avail themselves of others equally practicable. As a rule the more educated the patient, the more ingenious and varied are the methods adopted to attain the desired result.
The faculty of attention is variously affected in the subjects of insanity. In some the attention is entirely subjective, being occupied by sensations of misery, depression or sensory disturbances. In others the attention is objective, and attracted by every accidental sound or movement. In most of the early acute insanities the capacity of attention is wholly abolished, while in hebephrenia the stage of exhaustion which follows acute excitement, and the condition known as secondary dementia, loss of the power of attention is one of the most prominent symptoms. The memory for both recent and remote events is impaired or abolished in all acute insanities which are characterized by confusion and loss or impairment of consciousness. In the excited stage of manic-depressive insanity it is not uncommon to find that the memory is abnormally active. Loss of memory for recent but not remote events is characteristic of chronic alcoholism and senility and even the early stage of general paralysis.
Of all the functions of the brain that of sleep is the most liable to disorder in the insane. Sleeplessness is the earliest symptom in the onset of insanity; it is universally present in all the acute forms, and the return of natural sleep is generally the first symptom of recovery. The causes of sleeplessness are very numerous, but in the majority of acute cases the sleeplessness is due to a state of toxaemia. The toxins act either directly on the brain cells producing a state of irritability incompatible with sleep, or indirectly, producing physical symptoms which of themselves alone are capable of preventing the condition of sleep. These symptoms are high arterial tension and a rapid pulse-rate. The arterial tension of health ranges between 110 and 120 millimetres of mercury, and when sleep occurs the arterial tension falls and is rarely above 100 millimetres. In observations conducted by Bruce (Scottish Medical and Surgical Journal, August 1900) on cases of insanity suffering from sleeplessness the arterial tension was found to be as high as 140 and 150 millimetres. When such sleep was obtained the tension always sank at once to 110 millimetres or even lower. In a few cases suffering from sleeplessness the arterial tension was found to be below 100 millimetres, accompanied by a rapid pulse-rate. When sleep set in, in these cases, no alteration was noted in the arterial tension, but the pulse was markedly diminished.
Melancholia.—Melancholia is a general term applied to all forms of insanity in which the prevailing mental symptom is that of depression and dates back to the time of Hippocrates. Melancholic patients, however, differMelancholia.very widely from one another in their mental symptoms, and as a consequence a perfectly unwarrantable series of subdivisions have been invented according to the prominence of one or other mental symptoms. Such terms as delusional melancholia, resistive melancholia, stuporose melancholia, suicidal melancholia, religious melancholia, &c. have so arisen; they are, however, more descriptive of individual cases than indicative of types of disease.
So far as our present knowledge goes, at least three different and distinct disease conditions can be described under the general term melancholia. These are, acute melancholia, excited melancholia and the state of depression occurring inFolie circulaireor alternating insanity, a condition in which the patient is liable to suffer from alternating attacks of excitement and depression.
Acute Melancholiais a disease of adult life and the decline of life. Women appear to be more liable to be attacked than men. Hereditary predisposition, mental worry, exhausting occupations, such as the sick-nursing of relatives, are the chief predisposing causes, while the direct exciting cause of the condition is due to the accumulation in the tissues of waste products, which so load the blood as to act in a toxic manner on the cells and fibres of the brain.
The onset of the disease is gradual and indefinite. The patient suffers from malaise, indigestion, constipation and irregular, rapid and forcible action of the heart. The urine become scanty and high coloured. The nervous symptoms are irritability, sleeplessness and a feeling of mental confusion. The actual onset of the acute mental symptoms may be sudden, and is not infrequently heralded by distressing hallucinations of hearing, together with a rise in the body temperature. In the fully developed disease the patient is flushed and the skin hot and dry; the temperature is usually raised 1° above the normal in the evening. The pulse is hard, rapid and often irregular. There is no desire for food, but dryness of the mouth and tongue promote a condition of thirst. The bowels are constipated. The urine is scanty and frequently contains large quantities of indoxyl. The blood shows no demonstrable departure from the normal. The patient is depressed, the face has a strained, anxious expression, while more or less mental confusion is always present. Typical cases suffer from distressing aural hallucinations, and the function of sleep is in abeyance.
Acute melancholia may terminate in recovery either gradually or by crises, or the condition may pass into chronicity, while in a small proportion of cases death occurs early in the attack from exhaustion and toxaemia. The acute stage of onset generally lasts for from two to three weeks, and within that period the patient may make a rapid and sudden recovery. The skin becomes moist and perspiration is often profuse. Large quantities of urine are excreted, which are laden with waste products. The pulse becomes soft and compressible, sleep returns, and the depression, mental confusion and hallucinations pass away. In the majority of untreated cases, however, recovery is much more gradual. At the end of two or three weeks from the onset cf the attack the patient gradually passes into a condition of comparative tranquillity. The skin becomes moister, the pulse less rapid, and probably the earliest symptom of improvement is return of sleep. Hallucinations accompanied by delusions persist often for weeks and months, but as the patient improves physically the mental symptoms become less and less prominent.
If the patient does not recover, the physical symptoms are those of mal-nutrition, together with chronic gastric and intestinal disorder. The skin is dull and earthy in appearance, the hair dry, the nails brittle and the heart’s action weak and feeble. Mentally there is profound depression with delusions, and persistent or recurring attacks of hallucinations of hearing. When death occurs, it is usually preceded by a condition known as the “typhoid state.†The patient rapidly passes into a state of extreme exhaustion, the tongue is dry and cracked, sordes form upon the teeth and lips, diarrhoea and congestion of the lungs rapidly supervene and terminate life.
Treatment.—The patient in the early stage of the disease must be confined to bed and nursed by night as well as day. The food to begin with should be milk, diluted with hot water or aerated water, given frequently and in small quantities. The large intestine should be thoroughly cleared out by large enemata and kept empty by large normal saline enemata administered every second day. Sleep may be secured by lowering the blood pressure with half-grain doses of erythrol-tetra-nitrate. If a hypnotic is necessary, as it will be if the patient has had no natural sleep for two nights in succession, then a full dose of paraldehyde or veronal may be given at bed-time. Under this treatment the majority of cases, if treated early, improve rapidly. As the appetite returns great care must be taken that the patient does not suddenly resume a full ordinary dietary. A sudden return to a full dietary invariably means a relapse, which is often less amenable to treatment than the original attack. Toast should first be added to the milk, and this may be followed by milk puddings and farinaceous foods in small quantities. Any rise of temperature or increase of pulse-rate or tendency to sleeplessness should be regarded as a threatened relapse and treated accordingly.
Treatment.—The patient in the early stage of the disease must be confined to bed and nursed by night as well as day. The food to begin with should be milk, diluted with hot water or aerated water, given frequently and in small quantities. The large intestine should be thoroughly cleared out by large enemata and kept empty by large normal saline enemata administered every second day. Sleep may be secured by lowering the blood pressure with half-grain doses of erythrol-tetra-nitrate. If a hypnotic is necessary, as it will be if the patient has had no natural sleep for two nights in succession, then a full dose of paraldehyde or veronal may be given at bed-time. Under this treatment the majority of cases, if treated early, improve rapidly. As the appetite returns great care must be taken that the patient does not suddenly resume a full ordinary dietary. A sudden return to a full dietary invariably means a relapse, which is often less amenable to treatment than the original attack. Toast should first be added to the milk, and this may be followed by milk puddings and farinaceous foods in small quantities. Any rise of temperature or increase of pulse-rate or tendency to sleeplessness should be regarded as a threatened relapse and treated accordingly.
Excited Melancholia.—Excited melancholia is almost invariably a disease of old age or the decline of life, and it attacks men and women with equal frequency. Chronic gastric disorders, deficient food and sleep, unhealthy occupations and environments, together with worry and mental stress, are all more or less predisposing causes of the disease. The direct exciting cause or causes have not as yet been demonstrated, but there is no doubt that the disease is associated with, or caused by, a condition of bacterial toxaemia, analogous to the bacterial toxaemias of acute and chronic rheumatism.
The onset of the disease is always gradual and is associated with mal-nutrition, loss of body weight, nervousness, depression, loss of the capacity for work, sleeplessness and attacks ofrestlessness, these attacks of restlessness become more and more marked as self-control diminishes, and as the depression increases the disease passes the borderland of sanity.
In the fully developed disease the appearance of the patient is typical. The expression is drawn, depressed, anxious or apprehensive. The skin is yellow and parchment like. The hair is often dry and stands out stiffly from the head. The hands are in constant movement, twisting and untwisting, picking the skin, pulling at the hair or tearing at the clothes. The patient moans continuously, or emits cries of grief and wanders aimlessly. Mentally the patient, although depressed, miserable and self-absorbed, is not confused. There is complete consciousness except during the height of a paroxysm of restlessness and depression, and the patient can talk and answer questions clearly and intelligently, but takes no interest in the environment. Some of the patients suffer from delusions, generally a sense of impending danger, but very few suffer from hallucinations.
Physically there is loss of appetite, constipation and rapid heart action, a great increase in the number of the white blood corpuscles, particularly of the multinucleated cells which are frequently increased in bacterial infections. In the blood serum also there can be demonstrated the presence of agglutinines to certain members of the streptococci group.
The course of the disease is prolonged and chronic. The acute symptoms tend to remit at regular intervals, the patient becoming more quiet and less demonstratively depressed; but as a rule these remissions are extremely temporary. Excited melancholia is a disease characterized by repeated relapses, and recoveries are rare in cases above the age of forty.
Treatment.—There is no curative treatment for excited melancholia. The patient must be carefully nursed; kept in bed during the exacerbations of the disease and treated with graduated doses of nepenthe or tincture of opium, to secure some amelioration of the acute symptoms. Careful dieting, tonics and baths are of benefit during the remissions of the disease, and in a few cases seem to promote recovery.
Treatment.—There is no curative treatment for excited melancholia. The patient must be carefully nursed; kept in bed during the exacerbations of the disease and treated with graduated doses of nepenthe or tincture of opium, to secure some amelioration of the acute symptoms. Careful dieting, tonics and baths are of benefit during the remissions of the disease, and in a few cases seem to promote recovery.
Folie circulaire, or alternating insanity, was first described by Falret and Baillarger, and more recently Kraepelin has considerably widened the conception of this class of disease, which he describes under the term “manic-depressive insanity.†Of the two terms (folie circulaireand manic-depressive insanity) the latter is the more correct.Folie circulaireimplies that the disease invariably passes through a complete cycle, which description is only applicable to very few of the cases. Manic-depressive insanity implies that the patient may either suffer from excitement or depression which do not necessarily succeed one another in any fixed order. As a matter of fact, the majority of patients who suffer from the disease either have marked excited attacks with little or no subsequent depression, or marked attacks of depression with a subsequent period of such slight exaltation as hardly to be distinguished from a state of health.
Depression of the manic-depressive variety, therefore, may either precede or follow upon an attack of maniacal excitement, or it may be the chief and only obvious symptom of the disease and may recur again and again. The disease attacks men and women with equal frequency, and as a rule manifests itself either late in adolescence or during the decline of life. Hereditary predisposition has been proved to exist in over 50% of cases, beyond which no definite predisposing cause is at present known. A considerable number of cases follow upon attacks of infective disease such as typhoid fever, scarlet fever or rheumatic fever. The actual exciting cause is probably an intestinal toxaemia of bacterial origin; at all events, mal-nutrition, gastric and intestinal symptoms not infrequently precede an attack, and the condition of the blood—the increase in number in the multinucleated white blood corpuscles and the presence of agglutinines to certain members of the streptococci group of bacteria—are symptoms which have been definitely demonstrated by Bruce in every case so far examined.
If the depression is the sequel to an attack of excitement, the onset may be very sudden or it may be gradual. If, on the other hand, the depression is not the sequel of excitement, the onset is very gradual and the patient complains of lassitude, incapacity for mental or physical work, loss of appetite, constipation and sleeplessness often for months before the case is recognized as one of insanity. In the fully developed disease the temperature is very rarely febrile, on the contrary it is rather subnormal in character. The stomach is disordered and the bowels confined. The urine is scanty, turbid and very liable to rapid decomposition. The heart’s action is slow and feeble and the extremities become cold, blue and livid. In extreme cases gangrene of the lower extremities may occur, but in all there is a tendency to oedema of the extremities. The skin is greasy, often offensive, and the palms of the hands and the soles of the feet are sodden.
Mentally there is simple depression, without, in the majority of cases, any implication of consciousness. Many patients pass through attack after attack without suffering from hallucinations or delusions, but in rare cases hallucinations of hearing and sight are present. Delusions of unworthiness and unpardonable sin are not uncommon, and if once expressed are liable to recur again during the course of each successive attack. The disease is prolonged and chronic in its course, and the condition of the patient varies but little from day to day. When the depression follows excitement, the patient as a rule becomes fat and flabby. On the other hand, if the illness commences with depression, the chief physical symptoms are mal-nutrition and loss of body weight, and the return to health is always preceded by a return of nutrition and a gain in body weight.
The attacks may last from six months to two or three years. The intervals between attacks may last for only a few weeks or months or may extend over several years. During the interval the patient is not only capable of good mental work but may show capacity of a high order. In other words this form of mental disorder does not tend to produce dementia; the explanation probably being that between the attacks there is no toxaemia.
Treatment.—There is no known curative treatment for the depression of manic-depressive insanity, but the depression, the sleeplessness and the gastric disorder are to some extent mitigated by common sense attention to the general health of the body. If the patient is thin and wasted, then treatment is best conducted in bed. The diet should be bland, consisting largely of milk, eggs and farinaceous food, given in small quantities and frequently. Defecation should be maintained by enemata, and the skin kept clean by daily warm baths. What is of much more importance is the fact that in some instances subsequent attacks can be prevented by impressing upon the patient the necessity for attending to the state of the bowels, and of discontinuing work when the slightest symptoms of an attack present themselves. If these symptoms are at all prominent, rest in bed is a wise precaution, butcher-meat should be discontinued from the dietary and a tonic of arsenic or quinine and acid prescribed.
Treatment.—There is no known curative treatment for the depression of manic-depressive insanity, but the depression, the sleeplessness and the gastric disorder are to some extent mitigated by common sense attention to the general health of the body. If the patient is thin and wasted, then treatment is best conducted in bed. The diet should be bland, consisting largely of milk, eggs and farinaceous food, given in small quantities and frequently. Defecation should be maintained by enemata, and the skin kept clean by daily warm baths. What is of much more importance is the fact that in some instances subsequent attacks can be prevented by impressing upon the patient the necessity for attending to the state of the bowels, and of discontinuing work when the slightest symptoms of an attack present themselves. If these symptoms are at all prominent, rest in bed is a wise precaution, butcher-meat should be discontinued from the dietary and a tonic of arsenic or quinine and acid prescribed.
Mania.—The term mania, meaning pathological elevation or excitement, has, like the term melancholia, been applied to all varieties of morbid mental conditions in which the prevailing mental symptom is excitement or elevation.Mania.As in melancholia so in mania various subdivisions have been invented, such as delusional mania, religious mania, homicidal mania, according to the special mental characteristics of each case, but such varieties are of accidental origin and cannot be held to be subdivisions.
Under the term mania two distinct diseased conditions can be described, viz. acute mania, and the elevated stage offolie circulaireor manic-depressive insanity.
Acute Mania.—Acute mania is a disease which attacks both sexes at all ages, but its onset is most prevalent during adolescence and early adult life. Hereditary predisposition, physical and mental exhaustion, epileptic seizures and childbirth are all predisposing causes. The direct exciting cause or causes are unknown, but the physical symptoms suggest that the condition is one of acute toxaemia or poisoning, and the changes in the blood are such as are consequent on bacterial toxaemia.
The onset is gradual in the large majority of cases. Histories of sudden outbursts of mania can rarely be relied on, as the illness is almost invariably preceded by loss of body weight, sleeplessness, bad dreams, headaches and symptoms of general malaise, sometimes associated with depression. The actual onset of the mental symptoms themselves, however, are frequently sudden.A typical case of the fully developed disease is not easily mistaken. The patient is usually anaemic and thin, the expression of the face is unnatural, the eyes widely opened and bright; and there is great motor restlessness, the muscular movements being purposeless and inco-ordinate. This inco-ordination of movement affects not only the muscles of the limbs and trunk but also those of expression, so that the usual aspect of the face becomes entirely altered. The temperature is generally slightly febrile. The tongue and lips are cracked and dry through excessive shouting or speaking. There is often no desire for food or drink. The heart’s action is rapid and forcible. The skin is soft and moist. The urine is scanty, turbid and loaded with urates. The white blood corpuscles per cubic millimetre of blood are markedly increased, and the blood serum contains agglutinines to certain strains of streptococci which are not present in healthy persons. Sensibility to pain is lost or much impaired. Such patients will swing and jerk a broken limb apparently unaware that it is broken. Sleep is absent or obtained in short snatches, and even when asleep the patient is often restless and talkative as if the disease processes were still active.
Mentally the patient is excited, often wildly so, quite confused and unable to recognize time or place. Answers to questions may sometimes be elicited by repeated efforts to engage the attention of the patient. The speech is incoherent, and for all practical purposes the patient is mentally inaccessible. This state of acute excitement lasts usually for two or three weeks and gradually passes into a condition of chronic restlessness and noise, in which the movements are more coordinate and purposeful. The confusion of the acute stage passes off and the attention can be more readily attracted but cannot be concentrated on any subject for any length of time. The patient will now recognize friends, but the affections are in abeyance and the memory is defective. The appetite becomes insatiable, but the patient does not necessarily gain in weight. This stage of subacute excitement may last for months, but as a rule favourable cases recover within six months from the onset of the disease. A recovering patient gradually gains weight, sleeps soundly at night and has periods of partial quiescence during the day, particularly in the morning after a good night’s sleep. These lucid intervals become more and more prolonged and finally pass into a state of sanity. Some cases on the other hand, after the acute symptoms decline, remain confused, and this state of confusion may last for months; by some alienists it is described as secondary stupor.
The symptoms detailed above are those typical of an attack such as is most frequently met with in adult cases. Acute mania, however, is a disease which presents itself in various forms. Adolescent cases, for instance, very commonly suffer from recurrent attacks, and the recurrent form of the disease is also to be met with in adults. The recurrent form at the onset does not differ in symptoms from that already described, but the course of the attack is shorter and more acute, so that the patient after one or two weeks of acute excitement rapidly improves, the mental symptoms pass off and the patient is apparently perfectly recovered. An examination of the blood, however, reveals the fact that the patient is still suffering from some disorder of the system, inasmuch as the white blood corpuscles remain increased above the average of health. Subsequent attacks of excitement come on without any obvious provocation. The pulse becomes fast and the face flushed. The patient frequently complains of fullness in the head, ringing in the ears and a loss of appetite. Sleeplessness is an invariable symptom. Self-control is generally lost suddenly, and the patient rapidly passes into a state of delirious excitement, to recover again, apparently, in the course of a few weeks. Recurrent mania might therefore be regarded as a prolonged toxaemia, complicated at intervals by outbursts of delirious excitement. Acute mania in the majority of cases ends in recovery. In the continuous attack the recovery is gradual. In the recurrent cases the intervals between attacks become longer and the attacks less severe until they finally cease. In such recovered cases very frequently a persistent increase in the number of the white blood corpuscles is found, persisting for a period of two or three years of apparently sound mental health. A few cases die, exhausted by the acuteness of the excitement and inability to obtain rest by the natural process of sleep. When death does occur in this way the patient almost invariably passes into the typhoid state.
The residue of such cases become chronic, and chronicity almost invariably means subsequent dementia. The chronic stage of acute mania may be represented by a state of continuous subacute excitement in which the patient becomes dirty and destructive in habits and liable from time to time to exacerbations of the mental symptoms. Continuous observation of the blood made in such cases over a period extending for weeks reveals the fact that the leucocytosis, if represented in chart form, shows a regular sequence of events. Just prior to the onset of an exacerbation the leucocytosis is low. As the excitement increases in severity the leucocytosis curve rises, and just before improvement sets in there may be a decided rise in the curve and then a subsequent fall; but this fall rarely reaches the normal line. In other cases, which pass into chronicity, a state of persistent delusion, rather than excitement, is the prevailing mental characteristic, and these cases may at recurrent intervals become noisy and dangerous.
Treatment.—Acute mania can only be treated on general lines. During the acute stage of onset the patient should be placed in bed. If there is difficulty in inducing the patient to take a sufficient quantity of food, this difficulty can be got over by giving food in liquid form, milk, milk-tea, eggs beaten up in milk, meat juice and thin gruel, and it is always better to feed such a patient with small quantities given frequently. Cases of mania following childbirth are those which most urgently demand careful and frequent feeding, artificially administered if necessary. If there is any tendency to exhaustion, alcoholic stimulants are indicated, and in some cases strychnine, quinine and cardiac tonics are highly beneficial. The bowels should be unloaded by large enemata or the use of saline purgatives. The continuous use of purgatives should as a rule be avoided, as they drain the system of fluids. On the other hand, the administration of one large normal saline enema by supplying the tissues with fluids, and probably thereby diluting the toxins circulating in the system, gives considerable relief. A continuous warm bath frequently produces sleep and reduces excitement. The sleeplessness of acute mania is best treated by warm baths wherever possible, and if a drug must be administered, then paraldehyde is the safest and most certain, unless the patient is also an alcoholic, when chloral and bromide is probably a better sedative.
Treatment.—Acute mania can only be treated on general lines. During the acute stage of onset the patient should be placed in bed. If there is difficulty in inducing the patient to take a sufficient quantity of food, this difficulty can be got over by giving food in liquid form, milk, milk-tea, eggs beaten up in milk, meat juice and thin gruel, and it is always better to feed such a patient with small quantities given frequently. Cases of mania following childbirth are those which most urgently demand careful and frequent feeding, artificially administered if necessary. If there is any tendency to exhaustion, alcoholic stimulants are indicated, and in some cases strychnine, quinine and cardiac tonics are highly beneficial. The bowels should be unloaded by large enemata or the use of saline purgatives. The continuous use of purgatives should as a rule be avoided, as they drain the system of fluids. On the other hand, the administration of one large normal saline enema by supplying the tissues with fluids, and probably thereby diluting the toxins circulating in the system, gives considerable relief. A continuous warm bath frequently produces sleep and reduces excitement. The sleeplessness of acute mania is best treated by warm baths wherever possible, and if a drug must be administered, then paraldehyde is the safest and most certain, unless the patient is also an alcoholic, when chloral and bromide is probably a better sedative.
The Elevated Stage of Folie Circulaire or Manic Depressive Insanity.—As previously mentioned in the description of the depressed stage of this mental disorder, the disease is equally prone to attack men and women, generally during late adolescence or in early adult life, and in a few cases first appears during the decline of life. Hereditary predisposition undoubtedly plays a large part as a predisposing cause, and after that is said it is difficult to assign any other definite predisposing causes and certainly no exciting causes. As in the stage of depression, so in the stage of excitement the first attack may closely follow upon typhoid fever, erysipelas or rheumatic fever. On the other hand many cases occur without any such antecedent disease. Another fact which has been commented upon is that these patients at the onset of an attack of excitement often appear to be in excellent physical health.
The earliest symptoms of onset are moral rather than physical. The patient changes in character, generally for the worse. The sober man becomes intemperate. The steady man of business enters into foolish, reckless speculation. There is a tendency for the patient to seek the society of inferiors and to ignore the recognized conventionalities of life and decency. The dress becomes extravagant and vulgar and the speech loud, boastful and obscene. These symptoms may exist for a considerable period before some accidental circumstance or some more than usually extravagant departure from the laws and customs of civilization draws public attention to the condition of the patient. The symptoms of the fully developed disease differ in degree in different cases. The face is often flushed and the expression unnatural. There is constant restlessness, steady loss of body weight, and sleeplessness. In very acute attacks there are frequently symptoms of gastric disorder, while in other cases the appetite is enormous, gross and perverted. The leucocytosis is above that usually met with in health, and the increase in theearly stages is due to the relative and absolute increase in the multinucleated or polymorphonuclear leucocytes. The hyperleucocytosis is not, however, so high as it is in acute mania, and upon recovery taking place the leucocytosis always falls to normal. In the serum of over 80% of cases there are present agglutinines to certain strains of streptococci, which agglutinines are not present in the serum of healthy persons. The changes in the urine are those which one would expect to find in persons losing weight; the amount of nitrogenous output is in excess of the nitrogen ingested in the food.
Mentally there is always exaltation rather than excitement, and when excitement is present it is never of a delirious nature, that is to say, the patient is cognizant of the surroundings, and the special senses are abnormally acute, particularly those of sight and hearing. Hallucinations and delusion are sometimes present, but many cases pass through several attacks without exhibiting either of these classes of symptoms. The patient is always garrulous and delighted to make any chance acquaintance the confidant of his most private affairs. The mood is sometimes expansive and benevolent, interruption in the flow of talk may suddenly change the subject of the conversation or the patient may with equal suddenness fly into a violent rage, use foul and obscene language, ending with loud laughter and protestations of eternal friendship. In other words the mental processes are easily stimulated and as easily diverted into other channels. The train of thought is, as it were, constantly being changed by accidental associations. Although consciousness is not impaired, the power of work is abolished as the attention cannot be directed continuously to any subject, and yet the patient may be capable of writing letters in which facts and fiction are most ingeniously blended. A typical case will pass through the emotions of joy, sorrow and rage in the course of a few minutes. The memory is not impaired and is often hyper-acute. The speech may be rambling but is rarely incoherent.
The course of the attack is in some cases short, lasting for from one to three weeks, while in others the condition lasts for years. The patient remains in a state of constant restlessness, both of body and mind, untidy or absurd in dress, noisy, amorous, vindictive, boisterously happy or virulently abusive. As time passes a change sets in. The patient sleeps better, begins to lay on flesh, the sudden mental fluctuations become less marked and finally disappear. Many of these patients remember every detail of their lives during the state of elevation, and many are acutely ashamed of their actions during this period of their illness. As a sequel to the attack of elevation there is usually an attack of depression, but this is not a necessary sequel.
The majority of patients recover even after years of illness, but the attacks are always liable to recur. Even recurrent attacks, however, leave behind them little if any mental impairment.
Treatment.—General attention to the health of the body, and an abundance of nourishing food, and, where necessary, the use of sedatives such as bromide and sulphonal, sum up the treatment of the elevated stage of manic-depressive insanity. In Germany it is the custom to treat such cases in continuous warm baths, extending sometimes for weeks. The use of warm baths of several hours’ duration has not proved satisfactory.
Treatment.—General attention to the health of the body, and an abundance of nourishing food, and, where necessary, the use of sedatives such as bromide and sulphonal, sum up the treatment of the elevated stage of manic-depressive insanity. In Germany it is the custom to treat such cases in continuous warm baths, extending sometimes for weeks. The use of warm baths of several hours’ duration has not proved satisfactory.
Delusional Insanity.—Considerable confusion exists at the present day regarding the term delusional insanity. It is not correct to define the condition as a disease in which fixed delusions dominate the conduct and are theDelusional Insanity.chief mental symptom present. Such a definition would include many chronic cases of melancholia and mania. All patients who suffer from attacks of acute insanity and who do not recover tend to become delusional, and any attempt to include and describe such cases in a group by themselves and term them delusional insanity is inadmissible. The fact that delusional insanity has been described under such various terms as progressive systematized insanity, mania of persecution and grandeur, monomanias of persecution, unseen agency, grandeur and paranoia, indicates that the disease is obscure in its origin, probably passing through various stages, and in some instances having been confused with the terminal stages of mania and melancholia. If this is admitted, then probably the best description of the disease is that given by V. Magnan under the term of “systematized delusional insanity,†and it may be accepted that many cases conform very closely to Magnan’s description.
The disease occurs with equal frequency in men and women, and in the majority of cases commences during adolescence or early adult life. The universally accepted predisposing cause is hereditary predisposition. As to the exciting causes nothing is known beyond the fact that certain forms of disease, closely resembling delusional insanity, are apparently associated or caused by chronic alcoholism or occur as a sequel to syphilitic infection. In the vast majority of cases the onset is lost in obscurity, the patient only drawing attention to the diseased condition by insane conduct after the delusional state is definitely established. The friends of such persons frequently affirm that the patient has always been abnormal. However this may be, there is no doubt that in a few cases the onset is acute and closely resembles the onset of acute melancholia. The patient is depressed, confused, suffers from hallucinations of hearing and there are disturbances of the bodily health. There is generally mal-nutrition with dyspepsia and vague neuralgic pains, often referred to the heart and intestines. Even at this stage the patient may labour under delusions. These acute attacks are of short duration and the patient apparently recovers, but not uncommonly both hallucinations and delusions persist, although they may be concealed.
The second or delusional stage sets in very gradually. This is the stage in which the patient most frequently comes under medical examination. The appearance is always peculiar and unhealthy. The manner is unnatural and may suggest a state of suspicion. The nutrition of the body is below par, and the patient frequently complains of indefinite symptoms of malaise referred to the heart and abdomen. The heart’s action is often weak and irregular, but beyond these symptoms there are no special characteristic symptoms.
Mentally there may be depression when the patient is sullen and uncommunicative. It will be found, however, that he always suffers from hallucinations. At first hallucinations of hearing are the most prominent, but later all the special senses may be implicated. These hallucinations constantly annoy the patient and are always more troublesome at night. Voices make accusations through the walls, floors, roofs or door. Faces appear at the window and make grimaces. Poisonous gases are pumped into the room. Electricity, Röntgen rays and marconigrams play through the walls. The food is poisoned or consists of filth. In many cases symptoms of visceral discomfort are supposed to be the result of nightly surgical operations or sexual assaults. All these persecutions are ascribed to unknown persons or to some known person, sect or class. Under the influence of these sensory disturbances the patient may present symptoms of angry excitement, impulsive violence or of carefully-thought-out schemes of revenge; but the self-control may be such that although the symptoms are concealed the behaviour is peculiar and unreasonable. It is not uncommon to find that such patients can converse rationally and take an intelligent interest in their environments, but the implication of the capacity of judgment is at once apparent whenever the subject of the persecutions is touched upon.
All cases of delusional insanity at this stage are dangerous and their actions are not to be depended upon. Assaults are common, houses are set on fire, threatening letters are written and accusations are made which may lead to much worry and trouble before the true nature of the disease is realized.
This, the second or persecutory stage of delusional insanity, may persist through life. The patient becomes gradually accustomed to the sensory disturbances, or possibly a certain amount of mental enfeeblement sets in which reduces the mental vigour. In other cases, the disease goes on to what Magnan calls the third stage or stage of grandiose delusions. The onset of this stage is in some cases gradual. The patient, while inveighing against the persecutions, hints at a possible cause. One man is an inventor and his enemies desire to deprive him of the results of his inventions.Another is the rightful heir to a peerage, of which he is to be deprived. Women frequently believe themselves to be abducted princesses or heirs to the throne. Others of both sexes, even more ambitious, assume divine attributes and proclaim themselves Virgin Marys, Gabriels, Holy Ghosts and Messiahs. Cases are recorded in which the delusions of grandeur were of sudden onset, the patient going to bed persecuted and miserable and rising the following morning elated and grandiose. In this stage the hallucinations persist but appear to change in character and become pleasant. The king hears that arrangements are being made for his coronation and waits quietly for the event. The angel Gabriel sees visions in the heavens. The heirs and heiresses read of their prospective movements in the court columns of the daily papers and are much soothed thereby. In short, no delusion is too grotesque and absurd for such patients to believe and express.
Cases of delusional insanity never become demented in the true sense of the word, but their mental state might be described as a dream in which an imaginary existence obliterates the experiences of their past lives.
Treatment.—No treatment influences the course of the disease. During the stage of persecution such patients are a danger to themselves, as they not infrequently commit suicide, and to their supposed persecutors, whom they frequently assault or otherwise annoy.
Treatment.—No treatment influences the course of the disease. During the stage of persecution such patients are a danger to themselves, as they not infrequently commit suicide, and to their supposed persecutors, whom they frequently assault or otherwise annoy.
Katatonia.—This disease, so called on account of the symptom of muscular spasm or rigidity which is present during certain of its stages, was first described and named by K. L. Kahlbaum in 1874. Many British alienists refuse toKatatonia.accept katatonia as a distinct disease, but as it has been accepted and further elaborated by such an authority as E. Kraepelin reference to it cannot be avoided.
Katatonia attacks women more frequently than men, and is essentially a disease of adolescence, but typical cases occasionally occur in adults. Hereditary predisposition is present in over 50% of the cases and is the chief predisposing cause. Childbirth, worry, physical strain and mental shocks are all advanced as secondary predisposing causes. The disease is one of gradual onset, with loss of physical and mental energy. Probably the earliest mental symptom is the onset of aural hallucinations. For convenience of description the disease may be divided into (1) the stage of onset; (2) the stage of stupor; (3) the stage of excitement.
The symptoms of the stage of onset are disorders of the alimentary tract, such as loss of appetite, vomiting after food and obstinate constipation. The pulse is rapid, irregular and intermittent. The skin varies between extreme dryness and drenching perspirations. In women the menstrual function is suppressed. At uncertain intervals the skeletal muscles are thrown into a condition of rigidity, but this symptom does not occur invariably. The instincts of cleanliness are in abeyance, owing to the mental state of the patient, and as a result these cases are inclined to be wet and dirty in their habits.
Mentally there is great confusion, vivid hallucinations, which apparently come on at intervals and are of a terrifying nature, for the patient often becomes frightened, endeavours to hide in corners or escape by a window or door. A very common history of such a case prior to admission is that the patient has attempted suicide by jumping out of a window, the attempt being in reality an unconscious effort on the part of the patient to escape from some imaginary danger. During these attacks the skin pours with perspiration. The patient is oblivious to his surroundings and is mentally inaccessible. In the intervals between these attacks the patient may be conscious and capable of answering simple questions. This acute stage, in which sleep is abolished, lasts from a few days to four or six weeks and then, generally quite suddenly, the patient passes into the state of stupor. In some cases a sharp febrile attack accompanies the onset of the stupor, while in others this symptom is absent; but in every case examined by Bruce during the acute stage there was an increase in the number of the white blood corpuscles, which, just prior to the onset of stupor, were sometimes enormously increased; the increase being entirely due to multiplication of the multinucleated or polymorphonuclear leucocytes.
In the second or stuporose stage of the disease the symptoms are characteristic. The patient lies in a state of apparent placidity, generally with the eyes shut. Consciousness is never entirely abolished, and many of the patients give unmistakable evidence that they understand what is being said in their presence. Any effort at passive movement of a limb immediately sets up muscular resistance, and throughout this stage the sternomastoid and the abdominal muscles are more or less in a state of over-tension, which is increased to a condition of rigidity if the patient is interfered with in any way. This symptom of restiveness or negativism is one of the characteristics of the disease. The patient resists while being fed, washed, dressed and undressed, and even the normal stimuli which in a healthy man indicate that the bladder or rectum require to be emptied are resisted, so that the bladder may become distended and the lower bowel has to be emptied by enemata. The temperature is low, often subnormal, the pulse is small and weak, and the extremities cold and livid. This symptom is probably due in some part to spasm of the terminal arterioles. Mentally the symptoms are negative. Though conscious, the patient cannot be got to speak and apparently is oblivious to what is passing around. Upon recovery, however, these cases can often recount incidents which occurred to them during their illness, and may also state that they laboured under some delusion. Coincidently with the onset of the stupor sleep returns, and many cases sleep for the greater part of the twenty-four hours. The duration of the stuporose state is very variable. In some cases it lasts for weeks, in others for months or years, and may be the terminal stage of the disease, the patient gradually sinking into dementia or making a recovery. The third stage or stage of excitement comes on in many cases during the stage of stupor: the stages overlap; while in others a distinct interval of convalescence may intervene between the termination of the stupor and the onset of the excitement. The excitement is characterized by sudden impulsive actions, rhythmical repetition of words and sounds (verbigeration), and by rhythmical movements of the body or limbs, such as swaying the whole frame, nodding the head, swinging the arms, or walking in circles. The patient may be absolutely mute in this stage as in the stage of stupor. Others again are very noisy, singing, shouting or abusive. The speech is staccato in character and incoherent. Physically the patient, who often gains weight in the stage of stupor, again becomes thin and haggard in appearance owing to the incessant restlessness and sleeplessness which characterize the stage of excitement. The patient may, during the stage of onset, die through exhaustion, or accidentally and unconsciously commit suicide usually by leaping from a window. During the stuporose stage symptoms of tubercular disease of the lungs may commence. All the adolescent insane are peculiarly liable to contract and die from tubercular disease. Accidental suicide is also liable to occur during this stage. The stage of excitement, if at all prolonged, invariably ends in dementia. According to Kraepelin 13% of the cases recover, 27 make partial recoveries, and 60% become more or less demented.