MANIA.
Raving or Furious Madness.
Mania, Sauv. gen. 235. Lin. 68. Vog. 331. Sag. 349. Boerh. 1118. Junck. 122. Battie on Madness. Paraphrotyne, Lin. 66. Although these distempers may be considered as distinct genera, yet they are so nearly allied, and so readily change into each other, that it sufficiently justifies the treating all of them together.
The distinguishing characteristic of madness, according to Dr. Battie, is a false perception; and under this general character may be comprehended all kinds of what is called madness, from the most silly stupidity and idiotism to the most furious lunacy. Frequently the different kinds of madness are changed into each other by the casual excitement of some passion; thus, an idiot may become furiously mad, by being put in a violent passion; though this does not so often happen as the change of melancholy into the raving madness, and vice versa.
It is a very surprising circumstance, that mad people are not only less liable to be seized with infectious disorders than those who are in perfect health; but even when labouring under other diseases, if the patients chance to be seized with madness, they are sometimes freed from their former complaints. Of this kind Dr. Mead relates two very remarkable instances.
On the other hand, it has been known, that an intermittent fever, supervening upon madness of long standing, has proved a cure for the madness; the senses having returned when the fever terminated. Dr. Monro saw two instances of this himself; and mentions it as an observation made also by his predecessor in the care of Bethlehem hospital.
Another remarkable circumstance is, that immoderate joy, long continued, as effectually disorders the mind as anxiety and grief. For it was observable in the famous South Sea year, when so many immense fortunes were suddenly gained, and as suddenly lost, that more people had their heads turned, from the prodigious flow of unexpected riches, than from the entire loss of their whole substance.
Mad people, especially of the melancholic kind, sometimes obstinately persevere in doing things which must excite great pain; whence it should seem as if their minds were troubled with some distracting notions, which make them patiently bear the present distresses, lest more severe tortures should be inflicted; or possibly they may think, that, by thus tormenting the body, they render themselves more acceptable to the divine Being, and expiate the heinous sins of which they may imagine themselves to have been guilty.
It is, however, also highly probable, that their feelings differ exceedingly from what they are in a natural state; at least they are every day observed to endure, apparently without the smallest uneasiness, watching, hunger, and cold, to an extent which in a state of health would not only be highly distressing, but to the greater part of individuals would even prove fatal.
And this resistance of hunger, cold, and sleep, affords perhaps the best test for distinguishing cases of real insanity, from cases where the disease is only feigned, and appearances of it put on, to answer particular purposes; at least where this power of resistance is present, we have good reason to conclude that the affection is not feigned.
Cure. Although we be well acquainted with many of the remote causes of this disease, some of the principal of which have already been mentioned, yet we are still so ignorant of the influence of these upon the system, as giving a derangement of the mental faculties, that no general principles on which the cure may be conducted, can with any confidence be pointed out.
It may, however, be observed, that while some remedies seem to operate by producing an artificial termination of this complaint, many others have effect only as aiding a natural termination. And where a recovery from this disease does take place, it most frequently happens in consequence of a natural convalescence. All the species and degrees of madness which are hereditary, or that grow up with people from their early youth, are out of the power of physic; and so, for the most part, are all maniacal cases of more than one year's standing, from whatever source they may arise. Very often mere debility, the dregs of some particular disease, such as an ague, the small-pox, or a nervous fever, shall occasion different degrees of foolishness or madness. In these cases, the cure must not be attempted by evacuations; but, on the contrary, by nourishing diet, clear air, moderate exercise, and the use of wine; whereas, in almost all the other maniacal cases, which arise from different sources, and which come on in consequence of intemperate living, violent passions, or intense thinking, it is generally held, that evacuations of every kind are necessary, unless the constitution of the patient be such as absolutely forbids them.
Blood is most conveniently drawn either from the arm or jugulars; and if the weakness be such as renders it improper to take away much blood, we may apply cupping glasses to the occiput.
Vomiting, in weakly people, must be excited by the vinum ipecacuanhae; but in the more robust by emetic tartar or antimonial wine: the most efficacious cathartics are the infusion or tincture of black hellebore, or infusion of senna quickened with tincture of jalap; but if there be suppression of the menes, or of an habitual hemorrhoidal discharge, then aloetic purges will be more proper; and in some instances cooling saline purgatives, such as lixiviated tartar, are of great service. In general, mad people require very large doses, both of the emetics and cathartics, before any considerable operation ensues.
Dr. Monro affirms us, that the evacuation by vomiting is infinitely preferable to any other: the prodigious quantity of phlegm with which the patients in this disease abound, he says, is not to be overcome but by repeated emetics; and he observes, that the purges have not their right effect, or do not operate to so good purpose, until the phlegm be broken and attenuated by frequent emetics. He mentions the case of a gentleman who had laboured under a melancholy for three years, from which he was relieved entirely by the use of vomits and a proper regimen. Increasing the discharge by urine, is also of the greatest moment, especially when any degree of fever is present. The cutaneous discharges are also to be promoted; for which purpose the hot bath is of the highest service in maniacal cases. Hoffman affirms, that he has seen numerous instances, both of inveterate melancholy and raging madness, happily cured by means of warm bathing; Camphor has also been highly commended; but, if we can believe Dr Locker of Vienna, not very deservedly. Having found very good effects from a solution of this medicine in vinegar, he took it for granted that all the succeds was owing to the camphor; therefore, in order to give it a fair trial, he selected seven patients, and gave it in large doses of half a dram twice a day. This was continued for two months, and the doctor was surprised to find that only one of his patients received any benefit. He then returned the other six back to the camphorated julep made with vinegar, and in a few weeks four of them recovered the use of their reason. This inclined him to think that the virtue depended solely on the vinegar, and accordingly he began to make the trial. Common vinegar was first given; but after a little while he fixed on that which had been distilled, and gave about an ounce and a half of it every day; the patients having been previously prepared by bleeding and purging, which was repeated according as it was found necessary. He gives a list of eight patients who were cured by this method; some in six weeks, others in two months, and none of them took up more than three months in perfecting the cure. He does not indeed give the ages of the patients, nor mention the circumstances of the cases; he only mentions the day on which the use of the vinegar was begun and the day on which they were discharged; and he adds, that they all continued well at the time of his writing.
Dr Locker informs us, that this medicine acts chiefly as a sudorific; and he observed, that the more the patients sweated, the sooner they were cured: it was also found to promote the menstrual discharge in such as had been obstructed, or had too little of this salutary evacuation.
Both reason and experience show the necessity of confining such as are deprived of their senses; and no small share of the management consists in preventing them from hurting either themselves or others. It has sometimes been usual to chain and to beat them: but this is both cruel and absurd; since the contrivance called the strait waistcoat answers every purpose of restraining the patients without hurting them.
These waistcoats are made of ticken, or some such strong stuff; are open at the back, and laced on like a pair of stays; the sleeves are made tight, and long enough to cover the ends of the fingers, where they are drawn close with a string like a purse mouth, by which contrivance the patient has no power of his fingers; and when laid on his back in bed, and the arms brought across the chest, and fastened in that position by tying the sleeve-strings round the waist, he has no use of his hands. A broad strap of girth-web is then carried across the breast, and fastened to the bedstead, by which means the patient is confined on his back; and if he should be so outrageous as to require further restraint, the legs are secured by ligatures to the foot of the bed; or they may be secured by being both put into one bag not very wide, which may be more easily fixed than the feet themselves, at least without giving pain.
It is of great use in practice to bear in mind, that all mad people are cowardly, and can be awed even by the menacing look of a very expressive countenance; and when those who have charge of them once impress them with the notion of fear, they easily submit to anything that is required. The physician, however, should never deceive them in anything, but more especially with regard to their distemper: for as they are generally conscious of it themselves, they acquire a kind of reverence for those who know it; and by letting them see that he is thoroughly acquainted with their complaint, he may very often gain such an ascendant over them that they will readily follow his directions.
It is a more difficult matter to manage those whose madness is accompanied either with excessive joy or with great dejection and despondency, than those who are agitated with rage: and all that can be done is to endeavour to excite contrary ideas, by repressing the immoderate fits of laughter in the one kind by chiding or threatening (taking care, however, not absolutely to terrify them, which can never be done without danger, and has often added to the misery of the unhappy sufferer); and dispelling the gloomy thoughts in the other, by introducing pleasing concerts of music, or any other species of entertainment which the patients have been known to delight in while they had the use of their reason. Upon the whole, in the cure of insanity, more is perhaps to be effected by moral than by medical treatment. And this moral treatment should be as gentle as is consistent with safety. Chains, bolts, and severity of every kind are to be avoided as much as possible. But while great benefit is often derived from company and amusement, so also, on the other hand, solitary confinement is in not a few cases productive of the best effects.
Though blistering the head has generally been directed, Dr Mead says he has oftener found it to do harm than service: but he recommends ouches in the back; and advises to keep the head always close shaved, and to wash it from time to time with warm vinegar. Opium has by many been forbidden in maniacal cases, from a supposition that it always increases the disturbance; but there are instances where large doses of this medicine have been found to prove a cure, and perhaps if it were tried oftener we should find powerful effects from it: there certainly cannot much harm ensue from a few doses, which may be immediately diluted if they should be found to exasperate the disease.
The diet of maniacal patients ought to be perfectly light and thin: their meals should be moderate; but they should never be suffered to live too low, especially while they are under a course of physic: they should be obliged to observe great regularity in their hours: even their amusements should be such as are best suited to their disposition. After the disease appears to be subdued, chalybeate waters and the cold bath will be highly proper to strengthen their whole frame and secure them against a relapse.