In favor of paranoid dementia are mental deterioration and the more mobile character of the delusions. In délire chronique there are the constant presence of hallucinations and a progressive evolution of the disease. In the alcoholic delusion of jealousy we find less perfect systematization, the constant presence of hallucinations, the stigmata of alcoholism, and the tendency towards recovery. Prognosis and treatment. Reasoning insanity is a chronic, incurable affection which, as we have seen, entails no mental deterioration. The violence of the reactions almost always renders commitment necessary. There are no known means for combating the delusions. Psychic treatment has no influence whatever. CHAPTER V. MANIC DEPRESSIVE PSYCHOSES.1 MANIC depressive insanity is manifested in attacks presenting a double characteristic: a tendency towards recovery without intellectual enfeeblement and a tendency towards recurrency. From a symptomatic standpoint the attacks are of three types, which I shall describe successively: Manic type; § 1. MANIC TYPE. Mania presents itself in three principal forms: simple mania, delusional mania, and confused mania. We shall first study simple mania, which, more clearly than the other forms, exhibits the following four fundamental symptoms of the disease: Flight of ideas; Morbid euphoria and irritability; Impulsive character of the reactions; Motor excitement. 1 Kraepelin. Lehrbuch der Psychiatrie, Vol. II. - Weygandt. Ueber das manisch-depressives Irresein. Berlin. klin. Woch., 1901, Nos. 4 and 5. Simple Mania. Prodromata.-The phenomena of maniacal excitement are almost constantly preceded by a period of depression characterized by diminution of psychic activity, which sometimes amounts to a veritable melancholic state. Later on we shall see the importance of this prodromal period as an argument for the unity of manic depressive insanity. External aspect.-The face of the maniac is flushed, the eyes brilliant, the expression happy and animated. The manner and gestures indicate a state of ease contrasting often with the usual timidity of the patient. The dress is showy, ridiculous, and ornamented with gaudy trinkets; the clothes are disordered, perhaps put on inside out. In women a bodice excessively décolleté and the skirt raised too high show also the erotic tendencies. Intellectual disorders. — Lucidity is perfect, orientation and memory are intact. The attention, very mobile, is distracted by all external impressions. Associations of ideas, uncontrolled, are formed at random from similarities of sound, superficial resemblances, coexistences in time and space, etc. Flight of ideas is here encountered in its typical form. These two symptoms, mobility of attention and flight of ideas, are, as we have already seen, an expression of enfeeblement of the normal psychic activity and of the predominance of mental automatism. Under these conditions the capacity for intellectual labor is diminished. The judgment, which is largely dependent upon associations of ideas, is always profoundly disordered. Though occasionally the patient surprises one by the accuracy of his observation, it is always the result of a sort of automatic appreciation bearing upon some isolated fact. But since judgment necessitates the systematic grouping of a very considerable number of ideas, it is here either absent or at least impaired. A maniac who notices some slight defect in the dress of the examiner is incapable of appreciating the importance of an event or of an act. Affective disorders. — These consist in morbid euphoria and irritability. The euphoria is often very marked. Many patients after recovery declare that they had never felt so happy as they did during the attack. The maniac is pleased with everything, and the contrast is particularly striking when the excitement follows a period of depression (insanity of double form). The most imperturbable optimism replaces the pessimism of past days. Of disease insight there is no question at all; the subject "never before felt so well"; if he is "somewhat nervous" the fault is with his relatives, the physicians, or the nurses, who constantly interfere with him. With his intelligence and activity he could "easily conduct important and gigantic enterprises." If he were allowed liberty of action, he would show everybody what he is capable of. Sad impressions are dismissed with a vague remark or a joke. A maniac, reminded of the loss of his fortune in a fire (which incidentally was the cause of his disease), replied laughingly: "Money does not bring happiness, and besides I shall have earned twice as much six months from now." This optimism, however, is never so absurd as that of general paretics or of senile dements. Dumas cites the case of a general paretic who, reminded of the recent death of his two little daughters, replied: "Well, well! I shall resuscitate them." A maniac would never have given such an answer. The irritability is evident in the violent outbursts of anger which occur on the slightest provocation. The maniac will bear no contradiction and will accept no suggestions. The moral sense is always diminished; the sense of propriety is greatly affected. The maniac is cynical, dishonest, and mischievous. "He lies, cheats, and steals without the least scruple. He allows himself anything that in others he would condemn " (Wernicke). Quite frequently he will tease and mock others. If in the midst of his rambling speech some pointed or amusing remark occurs, it is always at the expense of others. Erotic tendencies form an integral part of the picture: the patients abandon themselves to them without shame. Men previously exemplary in habits go around with prostitutes. Young girls, normally very reserved in their manner, offer themselves to everybody. One frequently sees maniacs indulging in alcoholic excesses. The patient is incapable of appreciating the significance of his acts either before or after they are accomplished. The most deprecable acts are displayed with complacency and become the object of cynical pleasantries; compunction and scruples are absent. |