Part 42

_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 the early 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.

Delusional Insanity.

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 the 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.

Katatonia.

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 to 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.

_Treatment._--No treatment arrests or diverts the course of katatonia, and the acute symptoms of the disease as they arise must be treated on hospital principles.

Hebephrenia.

HEBEPHRENIA.--This is a disease of adolescence (Gr. [Greek: hêbê]) which was first described by Hecker and Kahlbaum and more recently by Kraepelin and other foreign workers. Hebephrenia is not yet recognized by British alienists. The descriptions of the disease are indefinite and confusing, but there are some grounds for the belief that such an entity does exist, although it is probably more correct to say that as yet the symptoms are very imperfectly understood. Hebephrenia is always a disease of adolescence and never occurs during adult life. It attacks women more frequently than men, and according to Kahlbaum hereditary predisposition to insanity is present in over 50% of the cases attacked. The onset of the disease is invariably associated with two symptoms. On the physical side an arrested or delayed development and on the mental a gradual failure of the power of attention and concentrated thought. The onset of the condition is always gradual and the symptoms which first attract attention are mental. The patient becomes restless, is unable to settle to work, becomes solitary and peculiar in habits and sometimes dissolute and mischievous. As the disease advances the patient becomes more and more enfeebled, laughs and mutters to himself and wanders aimlessly and without object. There is no natural curiosity, no interest in life and no desire for occupation. Later, delusions may appear and also hallucinations of hearing, and under their influence the patient may be impulsive and violent. Physically the subjects are always badly developed. The temperature is at times slightly elevated and at intervals the white blood corpuscles are markedly increased. The menstrual function in women is suppressed and both male and female cases are addicted to masturbation. According to Kraepelin 5% of the cases recover, 15% are so far relieved as to be able to live at home, but are mentally enfeebled, the remaining 80% become hopelessly demented. The patients who recover frequently show at the onset of their disease acute symptoms, such as mild excitement, slightly febrile temperature and quick pulse-rate. When recovery does take place there is marked improvement in development. The subjects of hebephrenia are peculiarly liable to tubercular infection and many die of phthisis.

There is no special treatment for hebephrenia beyond attention to the general health.

Traumatic Insanity.

INSANITY FOLLOWING UPON INJURIES TO THE BRAIN, OR APOPLEXIES OR TUMOURS OR ARTERIAL DEGENERATION. (a) _Traumatic Insanity._--Insanity following blows on the head is divided into (1) the forms in which the insanity immediately follows the accident; (2) the form in which there is an intermediate prodromal stage characterized by strange conduct and alteration in disposition; and (3) in which the mental symptoms occur months or years after the accident, which can have at most but a remote predisposing causal relation to the insanity. The cases which immediately succeed injuries to the head are in all respects similar to confusional insanity after operations or after fevers. There is generally a noisy incoherent delirium, accompanied by hallucinations of sight or of hearing, and fleeting unsystematized delusions. The physical symptoms present all the features of severe nervous shock.

In those cases in which there is an intervening prodromal condition, with altered character and disposition, there is usually a more or less severe accidental implication of the cortex cerebri, either by depression of bone or local hemorrhage, or meningitic sub-inflammatory local lesions. Most of the cases during the prodromal stage are sullen, morose or suspicious, and indifferent to their friends and surroundings. At the end of the prodromal stage there most usually occurs an attack of acute mania of a furious impulsive kind. The cases which for many years after injury are said to have remained sane will generally be found upon examination and inquiry to exhibit symptoms of hereditary degeneration or of acquired degeneracy, which may or may not be a consequence of the accident.

The most common site of vascular lesion is one of the branches of the middle cerebral artery within the sylvian fissure, or of one of the smaller branches of the same artery which go directly to supply the chief basal ganglia. When an artery like the middle cerebral or one of its branches becomes either through rupture or blocking of its lumen, incapable of performing its function of supplying nutrition to important cerebral areas, there ensues devitality of the nervous tissues, frequently followed by softening and chronic inflammation. It is these secondary changes which give rise to and maintain those peculiar mental aberrations known as post-apoplectic insanity.