Part 35

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.