GEN. I. SPEC. II.

B E. Mania exultans.

Elevated madness.

The illusion

often unconnected with the

cause of the disease.

γ

E. Mania despondens. Despondent madness.

State of the mind rarely explanatory of the exci

ting cause. Pathology.

E. Mania demens. Chaotic

madness.

bigger than his feet: "Like her", says Burton, “in Trallian, that supposed she could shake all the world with her finger, and was afraid to clench her hand lest she should crush the world to pieces like an apple" *.

Yet even here the train of thoughts or ideas which occupies the mind of the maniac in many instances throw no light whatever on the nature or origin of the complaint; and we can still less avail ourselves of them than in various cases of melancholy.

This is particularly observable in the THIRD VARIETY or DESPONDENT MADNESS; for though this modification of the disease may occasionally be produced by suspicion, terror, or a guilty conscience, it is far more frequently the result of a melancholic idiosyncrasy, or a debilitated state of the constitution at the time of the attack, in consequence of which the sensorial fluid is secreted perhaps even less freely, instead of more so, than in a condition of health: so that the patient sinks by degrees into a state of insensibility; unless he should be roused with false courage and find means to put an end to his existence before this period arrives.

In DEMENTIA or CHAOTIC MADNESS this state of sensorial exhaustion and consequent insensibility is still more obvious, though there is, perhaps, less constitutional tenPathology. dency to the depressing passions. The judgement is here more diseased and weakened than in any other form, and, none of the kindred faculties assuming a paramount power, there is a general anarchy and confusion in the ideas that flit over the sensory without connexion or asDescription sociation of any kind. And hence Pinel has admirably from Pinel. characterized it, as consisting in a " rapid succession or uninterrupted alternation of insulated ideas and evanescent and unconnected emotions; continually repeated acts of extravagance; complete forgetfulness of every previous state; diminished sensibility to external impressions; abolition of the faculty of judgement; perpetual activity without

66

Anat. of Melancholy. Part. 1. Sect S.

GEN. I. SPEC. II.

object or design, or any internal sense of its taking place" *.

E. Mania

Chaotic madness. Additional

features.

These maniacs are often ungovernable except by means demens. of coercion, but they are more easily restrained than those who are in a state of phrensy. They are intractable, and neither listen to entreaty or to menaces. Fear of corporal punishment, however makes them obey. They willingly avoid the light, burying themselves under the bed-clothes, or under the straw of their cells. They are totally regardless of decency and cleanliness, and from some strange motive are often found smearing themselves over with their excrement. For the most part they have little appetite, and refuse the food offered them; yet a sense of hunger seems sometimes to return with great keenness when they will greedily devour their feces. Of the nature of the ideas that take place in the sensory, and are expressed by an unintelligible muttering, we know nothing further than that, from the screams and howlings with which their jargon is accompanied, there can be no doubt that they are often excited by painful sensations of body or mind.

In reference

fourth va

It is happy for those who suffer under this as well as General under the preceding form, that they rarely sustain a long prognostics. conflict; the exhaustion of sensorial power by repeated to the paroxysms soon leading to a total torpitude, and consequently a death of the sensorial organ; though there are instances in which a paroxysm of more violence than usual has produced a favourable change, and suddenly restored the patient to his senses.

riety.

to the

In gloomy madness, in which there is often a chronic In reference affection of some of the abdominal organs co-operating third. with a diseased condition of the brain, we find least to justify hope; the patients generally become weakened by fresh paroxysms, and often sink into a state of idiotism.

to the first.

The first variety, on the contrary, if the constitution In reference have not been seriously broken down by intemperance, or the patient be not suddenly carried off by the violence of

* De l'Aliénation Mentale. Chap. 111. iii. §. 176.

GEN. I. SPEC. II. Ecphronia Mania. Madness.

In reference to the second.

Disease most easily

cured when produced by accidental causes.

Hence the frequent and easy cure of

the attack on its commencement, will often work its own cure by its own ardour; and will gradually soften into a soberer state from mere mental fatigue. While in the milder and more pleasureable modification of the second variety, in which the secretion of sensorial power is upon the whole perhaps less than in a condition of sanity (since, though the stimulus of the disease may tend to increase it a little, the total privation which the patient enjoys of all the vexations, and anxieties, and wearing vicissitudes of real life, reduce it to a moderated and even tenour it could not otherwise possess), nothing is more common than for maniacs to continue to a very advanced age. I am at this moment interested in the case of a clergyman who has reached his ninety-sixth year, and has been in a state of quiet insanity for more than half a century.

For the most part those are most easily as well as most rapidly cured, whose insanity, of whatever kind it be, has been produced by accidental causes, as intoxication, sudden transition from cold to heat, retention of habitual discharges, or a revulsion by a transfer of morbid action from other organs. And hence the comparative facility with which a cure is effected in insanity after child-birth. Whilst, on the contrary, those are least likely to obtain a permanent recovery who possess an hereditary taint; the disease may indeed leave them for a time, but, the moval when predisposition remaining, they commonly fall victims to fresh attacks after intervals of a year or two, or even of a few months.

puerperal insanity.

Most diffi

cult of re

accompa

nied with

an hereditary taint.

disease va

riable from

"Mania and melancholy", says Dr. Greding, writing Term of the while he was physician to the workhouse at Waldheim, "have continued half a year with some, and remained forty years and upward with others, among whom one patient only in this workhouse attained the age of eightyfive"*.

six months

to forty years, or longer.

First attack

easiest car

The chance of recovery is considerably greater upon ried off, es- the first than upon any subsequent attack, and especially pecially if under three if the disease have not exceeded three months' duration

months'

standing.

* Vermischte Schriften, ut supra, &c.

GEN. I.

SPEC. II.

Madness.

when the patient is first put under medical treatment. If it have, at this time, lasted a twelvemonth, the prospect Ecphronia of success is diminished by half: if two years, not above Mania. a fourth part as many recover; and if more than two years the expectation is small, though, where the second rative year is not much exceeded, a cure is by no means to be chance bedespaired of.

Compa

yond this term small.

process of two kinds :

The treatment of ecphronia has generally been dis- Curative cussed under the two heads of MEDICAL and MORAL. Both have undergone a very great improvement within the last medical twenty or thirty years; the first by being considerably simplified, the second by being more thoroughly studied and raised to a higher degree of importance.

and moral.

treatment.

minative.

Nothing can be more injudicious than the ordinary rou- Medical tine of MEDICAL TREATMENT, which, till within a few Formerly years, was equally employed in almost all the larger lu- too indiscrinatic establishments in our own country and on the continent, especially at Bethlem, the Hospice d' Humanité, and the Hotel Dieu; and which consisted in a course of venesections, emetics and purgatives administered in every case indiscriminately, and often, indeed, without even the personal inspection of the consulting physician or other superintending medical officer; and if to these means of cure we add the occasional use of bathing in various forms and various temperatures, we shall very nearly have exhausted the merely medical process that till of late was ordinarily had recourse to.

Upon the cruel and disgusting scenes which, from the late parliamentary inquiry, and the report of the Committee which followed, are well known to have occurred not long ago, in the largest and most celebrated receptacle of lunatics in this metropolis, it is now unnecessary to dwell. But from the official communication of M. Esquirol to the French government concerning the residences for lunatics throughout France, it is perfectly clear, that we have not transgressed in a greater degree than our neighbours. Filth, straw, and dirty rags, were all these miserable beings possessed in many depôts to mitigate the coldness of the air and the dampness of their paved,

GEN. I.

SPEC. II. Ecphronia Mania. Madness. Medical treatment.

A reducent plan when and how far advisable.

crammed, and suffocating cells. And in some instances they had neither straw nor rags, and were perfectly naked, except from a layer of dirt. "J'ai vu," says M. Esquirol, with just indignation, "un malheureux imbécile, tout nu et sans paille, couché sur le pavé. Exprimant mon étonnement d'un pareil abandon, le concierge me répondit que l' administration ne lui passait, pour chaque individu, qu' une botte de paille tous les quinze jours. Je fis remarquer à ce barbare que le chien qui veillait à la porte des aliénés etoit logé plus sainement, et qu' il avoit de la paille fraîche et en abondance. Cette remarque me valut un sourire de pitié. Et j'etois dans une des grandes villes de France"*. It is satisfactory, however, to know, that a more judicious and discriminative practice has in all these asylums been introduced since the above period, and that it has been followed by an abundant success.

Admitting the proximate cause of insanity to be in most cases an increased action of the vessels secreting the nervous fluid, venesection and cathartics and a general reducent regimen seem indicated as an ordinary mean of relief; and are unquestionably called for when the pulse is full and strong, and the temperament is sanguineous and the success which has so frequently accompanied this practice stamps it with the highest sanction it can receive. Venesection But there is great reason to believe that even where the where called demand for blood-letting is unequivocal, it has been carrepeated ex- ried to a mischievous extent, and ruined its own benefit. travagantly: Thus Plater made a point of repeating it once a week, and tells us that he has sometimes had recourse to it for seventy weeks running t.

for: has been

by Plater seventy times.

Caution necessary even from

the first :

Much caution, however, is necessary even in the first trial; for as a sound intellect depends apparently upon a certain degree of excitement in the sensorial vessels, and a certain quantity of the fluid secreted, derangment may take place also, as we have already observed, from dimi

Des Etablissemens des Aliénés en France, et des moyens d' ameliorer le sort de ces Infortunés. Paris, 1819.