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.—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 Delusional 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.