Placing the patient in an entirely healthy atmosphere is next in importance. In the very earliest stage quiet, recreation, change of scene, and association with a pleasant and judicious companion are often sufficient to effect a cure. If the disease is pronounced, rest and removal from sources of irritation are more important until convalescence, when travel may be tried. The question of removal from home and commitment to an asylum should be decided upon the grounds already stated in considering the general treatment of mental diseases. The degree in which the patient should have exercise, occupation, and recreation or be let alone will be determined for each individual case. The fact should be borne in mind that the disease is a debilitating one, and that it arises in conditions of mental or physical exhaustion. Massage and a modified rest-cure, without seclusion, are beneficial in some cases, especially of elderly people. Baths and the cold pack should be used with discrimination. Electricity, where it does not give rise or add to delusions, is a useful tonic, especially in passive cases. There are very few patients of such desperate frenzy as to require confinement of the hands, and that should only be done with an attendant close at hand. Whatever is done, nothing should be attempted which excites delusions unless it be absolutely necessary. Fresh air, and an abundance of it, are very important. Experience and careful study of the particular case will be needed to know how far to press the taking of food. But the necessary amount should be given by the stomach-tube if ordinary means fail, and it is better to use it early rather than tire the patient out with ineffectual attempts with spoons, etc. Whether the nasal or œsophageal tube be used—of which I prefer the latter—the greatest care should be taken not to inject food into the lungs, the throat being so devoid of sensitiveness sometimes that the tube may be passed into the trachea. Nutrient enemata may be relied upon for a week or two if the patient is in bed, but no longer.
Tonics are indicated—cod-liver oil with bark, the hypophosphites, dilute phosphoric acid, malt. Strychnia, iron, and quinine should be used with caution, as they often cause disagreeable headache with indisposition to sleep. Fattening food will be found useful in most cases. The few fat melancholies need nitrogenous food and graduated exercise. Constipation will be corrected in many cases by a full, laxative diet, cod-liver oil, malt, or it may be beer. Mineral water or Sprudel salts are usually indicated. A pill containing aloin, strychnia, belladonna, mastich, or even colocynth or podophyllin, may be needed in obstinate constipation.
Medicines to control restlessness and sleeplessness should be avoided if possible. Hydrate of chloral, opium, bromides, valerian, sometimes increase the difficulty, and the objections to their prolonged use are obvious, and yet they must sometimes be used for a time. The bromides, with cannabis indica, valerianate of zinc, camphor, and hyoscyamus, may serve an excellent purpose for a time. Opium and its preparations, where they agree, act like magic in producing mental calm and sleep. They may relieve constipation and increase the desire for food, but the danger of the opium habit is so great that their use should be decided upon only in extreme cases, and the effect should be watched from dose to dose, each one of which should be given under medical direction. Wilful masturbation, one of the signs of loss of self-control which occurs in the best of people, cannot be corrected by drugs or appliances, but only by constant watching and by placing the individual where his self-respect, as soon as it can be appealed to, will keep him from it. If it is uncontrollable and symptomatic, fresh air and exercise, and, if necessary, bromides or opiates in moderate doses, with a tonic (not iron), should be used.
MANIA (Manie, Exaltation générale), according to Morel, meant, in the original Greek, folie or madness, while Esquirol derives it from the Greek word meaning moon, making the words maniac and lunatic equivalent. The word mania is still used in this loose way, even by writers on mental disease, as a synonym of insanity. Its use is properly restricted to conditions of mental exhilaration or excitement with motor activity. The morbid anatomy of the disease is not yet made out, and the indications of hyperæmia observed in the acute stage after death are no greater than are found in diseases in which mania is not a symptom. In its final stages atrophic, degenerative, and inflammatory signs are abundant and well marked.
Simple mania18 (manie sans délire, manie raisonnante), an exaltation of the mental faculties similar to the exhilaration produced by too much wine, with an accelerated flow of ideas, impaired judgment, and motor activity, without definite delusions, delirium, or incoherence, has been called an insanity of action, affective insanity, folie raisonnante, and even moral insanity, from which it differs in being marked by constant mental elation and exaltation of the physical functions, and not necessarily by striking moral perversion. It is a mental erethism, an exaggerated gayety, an uncontrollable exhilaration, an unbounded joy, an excessive anxiety, a perpetual anger, unusually good spirits, increased intellectual and physical energy, with such striking loss of self-control, diminished powers of reflection, and so decided weakening of the judgment that all sorts of unwonted errors of commission or omission may be performed. Under its influence many fortunes have been lost, many reputations have been ruined, and the happiness of many families has been sacrificed before the existence of insanity was suspected, except possibly by a very few persons. Indeed, the wit is usually so sharpened, the flow of ideas often so clear and rapid, the capacity for brain- and body-work without fatigue is generally so increased, that not seldom the patient is remarked upon as being unusually well. The most troublesome symptoms arise from the tendency to squander property, to drink alcoholic liquors to excess, and, especially in women, to allow the exalted sexual desires to get control of the judgment and reason, thereby bringing about unfortunate marriages or scandalous relations with the opposite sex. In women there is commonly increased menstrual flow.
18 Also called by some writers moral insanity, folie morale, folie des actes, folie or manie instinctive.
The course of the disease is without material change, and the duration is from several weeks to a number of years. When it does not constitute the initial stage of other types of mental disease, especially severer forms of mania, circular insanity, general paralysis, or (in the neuropathic constitutions and at the critical ages) mental degeneration, the termination is in recovery in about 90 per cent. of the cases, although sometimes some moral impairment or deterioration in character remains for life. The recklessness incident to the disease leads to unusual risks, now and then to fatal accidents. Simple mania rarely becomes chronic.
TREATMENT involves the necessity of proper control to prevent scandals, disasters, and perhaps crimes. The matter of the degree of seclusion and control should be governed by the general considerations already mentioned in the general treatment of insanity, bearing in mind that repression of the motor energy, except to prevent exhaustion, does harm. The demand for food is enormous; its supply should be abundant and judiciously chosen with reference to easy digestion. Frequent prolonged warm baths and cool applications to the head are indicated, and the usual palliatives for headache, sleeplessness, constipation, etc. The surroundings should be such as to favor rest and undisturbed sleep, and to dispel sources of excitement, whether they arise in certain associations, localities, occupations, or persons.
Acute mania (Tobsucht) follows an incubative stage of simple melancholia, often of simple mania, and rarely bursts out without previous indications of disease. Delusions, unsystematized and illogical, are abundant; the ideas flow so rapidly that the mechanism of speech is not adequate to their expression; the motor excitement is intense. In the most severe forms there is mental confusion, delirium, incoherence of ideas, and furious muscular action, to the point often of acts of destructiveness and self-injury. The clothing is torn to shreds, and no act of violence is too wild not to be attempted without warning. The skin is hot, the tongue heavily coated, the pulse accelerated, the temperature elevated, more, probably, than would be accounted for by the physical activity—from one to two or three degrees—now and then, in conditions of exhaustion, a little below the normal. Just as there is liable to be maniacal frenzy in the course of severe melancholia, so in acute mania outbursts are seen of desperately suicidal melancholic frenzy. Unless great care is used to keep up the strength, and often in spite of it, exhaustion rapidly sets in, under the influence of which the symptoms are very much aggravated. The amenorrhœa in women in this condition is conservative.