Part 41

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.--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, differ 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 in _Folie circulaire_ or alternating insanity, a condition in which the patient is liable to suffer from alternating attacks of excitement and depression.

_Acute Melancholia_ is 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.

_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 of restlessness, 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.

_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 circulaire_ and manic-depressive insanity) the latter is the more correct. _Folie circulaire_ implies 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.

Mania.

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. 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 of _folie circulaire_ or 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.