The COURSE AND DURATION of acute mania vary within wide limits, with an average of not far from six months, with recoveries in about 60 per cent. of first cases uncomplicated by pneumonia, chronic disease, or a marked neuropathic state: 5 or 6 per cent. die, chiefly from pneumonia, phthisis, accidents, or exhaustion, seldom suicide. Incurable cases drop slowly into dementia or into chronic delusional insanity, the motor excitement subsiding. The delusional insanity may be simply a stage in the process toward dementia.
In the DIAGNOSIS of acute mania, unless great care is used, the physician sometimes finds that he has sent to the asylum a case of acute, especially infectious disease, in the early stage and with unusual manifestations of febrile delirium. The indications for avoiding this unfortunate mistake are care and time in making diagnoses.
In the TREATMENT of acute mania the matter of foremost importance is that the physician should be able to sufficiently control his patient to prevent harm, and that he should have him in such a place as to give him an abundance of fresh air, unhampered by annoying and irritating limitations of his free will, restrictions of his liberty, and repression of his motor excitement. The risks of injury to others must be reasonably provided against. It goes without saying that few homes meet these indications: very few people can command a house to be converted into a virtual hospital, with the care of trained physicians to direct every little detail of treatment, and proper nursing. The public asylum, therefore, or the private retreat must usually be depended upon. In the case of quiet young people, especially of young women whose illness may be of such a nature as to justify their marrying after recovery, and in the acute mania following childbirth, it is well worth the physician's while to make an effort to keep the patient in a private house when the conditions are such as to make such a course practicable. To the rest and quiet which may be had under such circumstances, with all the goings on of the house regulated to the patient's comfort and convenience, to prolonged hot baths, a full simple diet, given with the stomach-tube if necessary, as few medicines as can be got on with, the supervision of the nurses by some judicious member of the family, and the gentleness (combined, of course, with proper firmness) of home-influences, I attach very great importance in properly selected cases. But I attribute as much to the restful influence of keeping the patients among familiar scenes, and where some familiar face and voice can reassure them in their comparatively clear moments, instead of their being agitated and distressed to know how to account for the strange people and cell-like room of the insane ward to which they will awaken from their delirium in the hospital. It is something to avoid the excitement of commitment and removal to an asylum, with all that they involve, as well as the sight of demented patients, whose noise may make sleep impossible just when it is most needed. Acute mania seems to me to arise much less often than other mental diseases in definite associations which need to be escaped from for successful treatment.
The term subacute mania is used by some writers for the milder cases of acute mania, just as acute delirious mania is a term which is applied to those violent cases of acute mania in which furious and prolonged delirium marks the disease, and in which there is a high death-rate and low proportion of recoveries.
In chronic mania the motor excitement, mental instability, and, sooner or later, delusions, if not present at the beginning, as is usual, continue. The progress to dementia is commonly slow, and there are few cases which it is wise to treat away from an asylum or its dependencies on account of the possible danger to others from sudden exacerbations of the disease or through uncontrolled violent impulses.
Although there is no pathological condition distinctive of mania in its curable stage, conditions indicating hyperæmia are usually found, whether as a result of the disease or its underlying cause, and sometimes meningitis. In chronic mania there is in the terminal stages evidence of atrophic and degenerative changes which do not distinguish it from other forms of mental disease.
ACUTE DELIRIUM is the typhomania of Bell. Its prevailing mental state is of mania oftener than of melancholia. It resembles the worst cases of typhoid fever so closely, and it is so uncommon a form of disease, that the mistake has often been made of sending typhoid-fever patients to insane asylums. The mistake is unnecessary, as the clinical features of typhoid fever are so well marked that with sufficient care and delay they may be recognized if the physician does not commit the common error in mania of being too much afraid of his patient to examine him thoroughly. The tendency to exhaustion in acute delirium is rarely successfully combated, as the motor excitement is so intense and the delirium so furious that nourishment to meet the tremendous demands of the system can seldom be given, and death is the usual result. Recoveries are rare, but less uncommon in the melancholic than in the maniacal form.
Little need be said in the way of TREATMENT, except that in so speedily fatal a disease it is well to keep the patient at home, if he can be properly cared for there.
TRANSITORY INSANITY is used by Krafft-Ebing19 (Transitorisches Irresein) as indicating mental disease differing from other insanity only in the fact that it is of short duration—namely, from two to six days. If it is applied to sudden and transient outbursts of mania, with delirium, loss of power of self-control, and inability to clearly recollect the circumstances of the attack and what happened during its continuance, it is a rare disease, occurring for the most part in epileptics and in persons under the influence of alcohol or addicted to its habitual use. It is sometimes, under the latter-named condition, called alcoholic trance. It consists in an automatic state resembling the epileptic delirium, which may occur also in sleep and resemble somnambulism. The actions are guided by co-ordinated will without conscious intelligence, and may consist in crimes and brutalities and foolishness entirely inconsistent with the character in health. It seldom lasts more than a few hours. When caused by alcohol or as a symptom of epilepsy, it may occur without other marked inciting cause; otherwise it is commonly due to mental shock. Several cases happened during the mental excitement of the first battle in our civil war. The most striking case within my own experience was that of a man who under the strain of prolonged grief and the mental shock of a great fire destroying a large part of the town in which he lived, perhaps moderately affected by alcohol, suddenly grasped an axe and cut off with one blow the head of a beloved child. He was found in the street without knowing how he had got there or what he had done.
19 Irrenfreund, 1883, p. 113.