Part 21

The other most common type of functional mental disease is mania. This is a form of insanity characterised by exaltation of spirits with a rapid flow of ideas and a distinct tendency to muscular agitation. It is almost exactly the opposite of melancholia in every symptom. Originally, of course, mania meant any form of madness. Then it became gradually limited to those forms of insanity which differed from melancholia. Now it has come to have a meaning as an acute attack of mental exaltation. It is necessary to remember this development of signification in reading the older literature on the subject of mental disturbance.

Professor Berkley calls attention to the fact that Shakespeare's statement, "Melancholy is the nurse of frenzy," may have been founded upon the observation that there are {223} few cases of mental exaltation without a forerunning stage of depression. It is characteristic of the acuity of observation of the poet whose works have created so much discussion as to his early training, that this association of mental states, which became an accepted scientific truth only during the last century, should have been anticipated in a passing remark in the development of a dramatic character. Melancholia precedes mania so constantly that it is not an unusual mistake in diagnosis to consider a patient melancholic when an outbreak of mania is really preparing.

Mania is sometimes said to break out suddenly. As a matter of fact there are always preliminary symptoms; though these are of such a general nature that they may have escaped observation. The patient's history generally shows that there has been loss of appetite and consequent loss in weight, commonly accompanied by constipation and headache with increasing inability to sleep. Usually these symptoms have been present at least for some weeks or a month or more. Then the patient brightens up. Instead of the brooding so common before, there is a tendency to talkativeness; the eye is bright; the expression lively; in the midst of his loquacity the patient becomes facetious and jocular. The backward before become enterprising. Undertakings are attempted that are evidently far beyond the power, pecuniary or mental, of the individual. Active employment is sought, and, where this fails, restless to and fro movement becomes the habit.

Friends notice this change in disposition, and also note a certain lack of connection in the ideas. There is apt to be a distinct change of disposition. A man who has been very loath to make friends before, now becomes easy in his manner toward strangers and takes many people into his confidence. In the severer forms motion becomes constant; the arms are thrown around; to and fro movement at least is kept up; the voice becomes loud and is constantly used. Patients can not be kept quiet, and, as a consequence of their constant movement, their temperature rises and loss of sleep makes them weaker and weaker until perhaps physical exhaustion ensues.

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The causes of mania are not always so distinctly traceable as those of melancholia. Heredity is an important factor. This is, however, not so much a question of actual direct inheritance of mental disturbance from the preceding generation, as a family trait of mental weakness that can be traced through many generations. Direct inheritance of acquired peculiarities no scientific thinker now admits. Family peculiarities, however, are traceable through many generations. So striking a peculiarity as the possession of six fingers or six toes has been traced through a majority of the members of as many as five generations in a single family. And as has been said other family traits can be traced back in the same way.

It would not be entirely surprising, then, if mental peculiarities and a predisposition to mental disturbance should be also a matter of inheritance. It is well known now that the physical condition of the brain substance may have much to do with the intellectual functions. Injuries to certain parts of the brain may cause special changes even of personal disposition. In the famous crowbar case, in which an iron drill over four feet in length was driven through one side of the head, it was noted that the man, who had been somewhat morose before, was inclined to be more amiable afterwards, but also had a tendency to be bibulous in his habits.

German clinicians have recently pointed out that the existence of an excess of pressure on the frontal lobes of the brain, such as is produced by the presence of a tumour, may cause a tendency to make little jokes. This symptom is known as "Witzelsucht." It is considered of distinct significance and value in localising tumours of the brain. The question of the type of the witticisms and particularly a tendency to obscenity are noted as a special diagnostic aid in the recognition of the character of these tumours by at least three prominent German medical observers.

If modifications of the brain substance can produce changes of disposition and temperament, it is easy to understand how temperament and disposition may be a matter of inheritance. If we inherit a father's nose and a mother's eyes, {225} the minutest conformations of brain substance may also be inherited. It is on these, to a certain extent at least, that the general outlines of the disposition depend. It would not be surprising to find, then, a disposition to mental unsteadiness as the result of the transmission of brain peculiarities. Here, as in everything else, there is question, not merely of parental influence, but of the inheritance of the family traits, some of which are skipped in certain generations.

When melancholia and mania are said to be due to heredity as one of the principal causes, the meaning intended is that in certain families the brain tissues are liable to be transmitted in somewhat impaired condition, and that through these brain tissues the mind will either not act properly, or under the stress of violent emotion, the loss of friends by death, or the loss of fortune, or serious disappointments in life, or a love affair, the already tottering mental condition will be overturned. In a word, it is not the direct transmission of insanity, but of a predisposition to the development of insanity under stresses and strains that is a matter of family inheritance. This is considered true now not only of mental but of all diseases. Not consumption, but the predisposition to it is inherited.

These considerations make clear how important this matter of heredity is. Physicians and students of anthropology are so much concerned about the increase of insanity as the result of the intermarriage of defectives that we are constantly reading in the newspapers of attempts at the legal regulations of marriage, so as to prevent further racial degeneration. Under present circumstances, any such legal regulation is probably impossible; but it seems perfectly clear that clerical influence should be brought to bear to discourage, as far as possible, intermarriage among those of even slightly disturbed mental heredity. Especially must any such idea as the possible beneficial influence of matrimony (for there are popular traditions to this effect) be unhesitatingly rejected and it must not be allowed to tempt those interested to look on such intermarriage with indifference.

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Another and more serious question for the clergyman is that of the vocation in life of those who are weak mentally. By vocation is meant not only religious calling, but the occupation in life generally. Young people of unstable mentality and especially those of insane heredity should be advised against taking up such professions as that of actor or actress, or broker, or other life duties that entail excitement and mental strain. As far as possible they should be discouraged from taking up city life, and should be advised to live quietly in the country.

Mania is apt to follow certain severe infectious diseases in delicate individuals. Pneumonia, for instance, or typhoid fever or chorea, and sometimes consumption or rheumatism, may be followed by a period of maniacal excitement. Severe injury to the brain or the pressure due to the presence of a brain tumour, may also be a cause of mania. A certain number of good authorities in mental diseases have called attention to the fact that mania is a little more liable to occur in patients who are suffering from heart disease. By this is meant in persons who have some organic lesion of the valvular mechanism of the heart. This leads to disturbance of the circulation and interferes with cerebral nutrition, thus predisposing to functional brain disturbance.

While melancholia occurs very frequently in older people, mania is almost essentially a mental disease of the young. The vast majority of cases occur between the twelfth and thirty-fifth year. The subjects of the disease are usually those who possess what is called the sanguine temperament, that is, hopeful, enthusiastic people, easily excited and aroused, easily cast down. Mania is much more common in females than in males.

One of the important characteristics of mania is the super-excitation of the sexual faculty. In many individuals the first sign of their mental disequilibration noticed by friends is a tendency to sexual excess. This is true of women as well as of men, and the extent to which this may manifest itself is almost unlimited. At the beginning of the disease this symptom is often a source of serious misunderstanding, and may be the cause of family disruption. Usually, before {227} there are any open insane manifestations, there are definite symptoms that would point to a pathological excitement in the sexual sphere.

One of the most striking characteristics of maniacal patients is the anaesthesia that often develops and is maintained in spite of the most serious injury. Because of this, maniacal patients should be guarded with quite as much care as those suffering from melancholia. I have seen a patient who, during an attack of acute mania, had put her hand over a lighted gas jet, holding it there until the tissues were completely charred. The burner was behind an iron grating, but she succeeded in reaching it. Neither from this dreadful burning itself, nor during the after dressings, did she complain of the slightest pain. Because of this anaesthetic condition and the consequent lack of complaint, maniacal patients often suffer from severe internal trouble without the medical attendant having any suspicion of its existence. There are few conditions that are more painful, for instance, than peritonitis, yet maniacal patients have been known to suffer and die from peritonitis, due to intestinal or gastric perforation, without a single complaint.

Unexpected death frequently occurs in mania because of the failure to recognise the existence of serious pathological conditions. Pneumonia may develop, for instance, without the slightest complaint on the part of the patient and go rapidly on to a fatal termination during the exhaustion incident to the constant movement, it being utterly impossible to confine the patient to bed. Meningitis may develop in the same way and proceed to a fatal issue without the patient's making any complaint or any sign that will call attention to its existence. In the meantime, the patient may be constantly in the wildest motion and so add to the exhausting effect of the organic disease.

The prognosis of acute mania is not unfavourable. Patients suffering from a first attack will recover completely in eight cases out of ten. Notwithstanding complete recovery, relapses are prone to occur whenever the patient undergoes a severe emotional strain. As a rule not nearly so much mental disturbance is required to produce a second attack {228} as the first one, so that patients require great care. In a certain number of cases recovery is incomplete; persistent delusions remain, and there may even be some weakness of intelligence. Paranoia, as it is called, mild delusional insanity, may assert itself and then may persist for the rest of life. Notwithstanding this, patients may get along in life reasonably well, though their mental condition is decidedly below the normal.

In a certain number of cases, after the period of excitement disappears, a certain amount of dementia is noticed. This consists of a distinct lowering of the intelligence, though without the presence of any special delusion. This dementia progresses until finally there is a state of almost complete obliteration of the mental faculties. The prognosis as to life in cases of mania is very good. Very few patients die during an attack of acute mania. At times there is a development of tuberculosis that proves fatal, because of the restlessness of the individual. Pneumonia or typhoid fever may also prove fatal.

Besides mania or melancholia, there is a third form of functional mental disease, which is a combination of these two forms. It is usually spoken of as circular insanity. The patient has usually first an attack of melancholia, then an attack of mania, and then after an interval melancholia and mania once more. We have said that most cases of mania develop after a distinct stage of depression of spirits, so that successive attacks of mania take partly the character of circular insanity. This latter disease, however, is an index of a much more degenerated mental state of the individual than is either mania or melancholia alone. When it occurs, the prognosis as to future sanity for any lengthy interval is unfavourable. A series of attacks alternately of depression and excitement finally make it necessary to confine the patient to an institution.

As might be expected in this severer form of mental disturbance, heredity plays an especially important part in circular insanity. At least 70 per centum of the patients affected show a family history of insanity in some forms. In this disease direct inheritance of this particular form of {229} mental disturbance is noticeably frequent. The patients who develop this form of insanity usually show marked signs of degeneration, even before any attack of absolute mental disturbance has occurred. Wounds of the head, alcoholism, and epilepsy are prominent factors in the production of circular insanity. This only means that the predisposition to mental disequilibration is so strong that but very little is required to disturb the intellectual equilibrium.

Fortunately, circular insanity is rare. In 40,000 cases of insanity in New York State, only 96 cases of this form were noted. Mild types of the disease are not, however, very rare. Many otherwise sane people have alternating periods of hopeful excitement and of discouraging depression, not momentary but enduring for weeks at a time, which are really due to the same functional disturbances that in people of less stable mentality produce absolute insanity. These cases are of special interest to the clergyman and to directors of consciences.

JAMES J. WALSH.

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XVIII

NEURASTHENIA

Neurasthenia, or nerve-weakness, "the vapours" of the old novelists and dramatists, is a very common malady, and it gives the clergyman trouble by the turmoil it causes in families, religious communities, in themselves, and elsewhere. Whether the condition is a distinct disease or not, and that question has been voluminously discussed, is not altogether an important matter, but that there is such a group of symptoms is unfortunately a weighty fact. It takes so many forms that it is bewildering, and therefore not readily reduced to unity.

The cerebral form often exists independently. There is such a thing as "brain fag," although many complainants may have very little material for the fag to work on. Often such a patient is robust, even an athlete, and his assertions meet with ridicule or abuse instead of treatment. If the patient is a woman she is not seldom called "hysterical." She is not hysterical. Hysteria, by the way, is as distinct a trouble as a broken leg, and far more serious, and not a synonym for perverseness, as the term is popularly used.

In the cerebral form, business, reading, study "go into one ear and out the other." The patient's memory fails him temporarily just when he may need it most, say, in a speech or sermon; a fly buzzing on a pane is a calamity and a source of profanity; a flat note in the choir-singing is ample reason for doubting the divine origin of the church, and every petty trouble that whisks its harmless tail across his floor makes him seek the table-top. I have known a whole convent of nuns, who were closely shut in, with bad ventilation and a worse cook, until all were more or less neurasthenic, almost {231} disintegrated by the presence of a lamb sent in as a pet; not because of the bleating or any ordinary reason, but solely because of the hideous incongruity and indecency in the fact that the lamb was a male.

The cerebral neurasthenic makes rash, impetuous changes in his mode of life. He leaves a religious order because the coffee is weak, he resigns an important post in a bank because the president uses snuff, he abandons medicine for trade because the curate meddled in the treatment of two of his patients. He takes on anxiety, locks up the house six times over the same night; meals are eaten in awed silence by his trembling children; altogether he is an unmitigated nuisance.

He may get religious scruples. If he is a priest he takes an hour to an hour and a half to say a low mass, and most of that time is spent in searching the corporal for imaginary particles or in drying the dry chalice. He rereads his breviary until he is exhausted. Because moral theologians say that certain scruples are from the devil, he is convinced that the devil takes a particular interest in his case. The devil did probably take a special interest in his father's or grandfather's lack of scrupulosity, for his condition is commonly a result of alcoholism in an ancestor.

There are three chief types of neurasthenics: in one class is the person that appears robust, and is really so except in his nervous system, which lacks a governor. Such patients have little more than a troubled appearance to draw the attention of a chance observer to their condition.

A second class is made up of eloquent narrators of their troubles. They try all the physicians in turn, then the homoeopaths and osteopaths and similar quacks, and they add patent medicines prescribed by themselves. They are petulant, capricious, and despite their apparent energy they accomplish nothing.

The third class are silent, limp, clammy-handed; they are brought against their will to see the physician; they are sulky; bitter and unreasoning haters; inclined to melancholy. They may have a tendency even to suicide, but this is somewhat rare. Neurasthenics are not so liable to insanity as is popularly supposed, but such an outcome is possible in certain {232} cases. If their vague fears go on into a more or less fixed delusion there is cause for anxiety lest insanity result, but care should be taken here to be sure the delusion is really irremovable.

Some neurasthenics are afraid to cross an open square or a wide street, others dread any closed apartment. Vertigo is common; so is insomnia. Insomnia is almost a constant symptom. The patient may have naps or he may have uninterrupted vigils. Sometimes there is a heavy but unrefreshing sleep. Sleepless patients are thrown into distracting rage by the barking of a neighbour's dog, the howling of cats, or the cackling of a successful hen, and they haunt the magistrates' courts in efforts to suppress such noises. They put cotton in their ears, wear heavy nightcaps, stop clocks, board up windows in search of sleep, which is not found.

These patients commonly have an enduring feeling of weight or constriction in the head, especially at the occiput,--a headache that is not actual pain. They also have vertigo, which is independent of any aural disease, and this is transient, showing itself on abrupt changes of position.

Another phase of neurasthenia is spinal. These cases have pain in the back and their legs give out. The back-pain is a diffuse ache, or it manifests itself on pressure at certain spots along the spine. There may be severe pain at the coccyx, especially in women. The walking may simulate paralytic forms if hysteria is mixed with the neurasthenia. Cardiac symptoms are often prominent, especially palpitation, but there is a nervous excitation of the heart rather than any definite lesion.

The gastro-intestinal symptoms are often important. Pain referred to the stomach and acidity are common, the tongue is coated, the faeces scybalous. Digestion is torpid. Sometimes there is nervous diarrhoea. A list of the belly symptoms described by some neurasthenics is interminable.

We often find a sexual form, which is the worst of all and the hardest to cure. It is commonly connected with masturbation. Such neurasthenics are shameless in the description of their nastiness. It is better to keep them from marriage unless they are cured, and they are not to be foisted off on {233} any one as husband or wife to effect a cure. Allbutt says of them: "I fear that some of our 'criminal psychologists' are encouraging many sorts of prurient debauchees by dignifying the tales of their vice with the name of science, a course of conduct which is in the worst interests both of these persons themselves and of our own profession. It were a curious inquiry how it comes that sexual perversions are so 'scientific' a study, while the brutalities of the thieves' kitchen or the wiles of other pests of society lie in comparative neglect."

Physical, intellectual, or emotional strain can cause neurasthenia suddenly or gradually. Where it comes on without obvious cause there is commonly a bad family history of nervousness or alcoholism. Anaemia makes it worse; eye-strain, too, is a provoking factor. In some cases a renal congestion is the cause. In many cases a lack of restraint, bad education, uncontrolled passion, are a marked influence in fixing the neurasthenic habit. A sedulous parent nags at a neurasthenic child that is too weak for exertion until the child's susceptibility to correction is blunted. Instead of treatment and help the child receives cuffs and abuse, and hell-fire is held up before him until he deems all religious talk dust and ashes. Encouragement will sometimes do more good than all the threats in the _via purgativa_. Nagging never cured anything except a tendency toward virtue, and it always deepens neurasthenia. Be careful in the selection of a confessor for a neurasthenic child. Get one that does not believe in kicking a soul into paradise.

The treatment of neurasthenia is difficult. Traveling about in search of health is not advisable. The Weir Mitchell Rest Cure is very effective in many bad cases, but it is costly, and if not correctly applied it is useless. It is the only cure for some patients. Sea air helps a certain class of neurasthenics, but it makes others worse--it is bad for the dyspeptic neurasthenic. A chronic rhinitis, a refractive error of the eyes, a displacement of the uterus, a congested kidney, a floating kidney, a tight prepuce, and similar teasing disorders must be cured before the neurasthenia can be removed; often the neurasthenia disappears with this cure.

Traumatic neurasthenia is like simple neurasthenia in {234} most details. It is called also nerve shock, spinal irritation, railway spine. There is always a causative shock or injury, which is followed at once or after an interval by the symptoms of neurasthenia. In acute traumatic neurasthenia there may be, in addition to the symptoms observed in simple neurasthenia, high fever, and such a fever has been observed to go as high as 113 degrees Fahrenheit.

AUSTIN ÓMALLEY.

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XIX

HYSTERIA