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History of Psychiatry

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Dissertation on acute mania


Diego Alcorta
History of Psychiatry 1991; 2; 211
DOI: 10.1177/0957154X9100200608
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DIEGO ALCORTA

(University of Buenos Aires, 26 June 1827)

1
Dissertation on acute mania

The mind of

man has always been of the greatest interest to the philosopher: as


attribute
of the human species, it has inevitably demanded explanation.
unique
In the absence of clear information, from which to draw logical conclusions,
eminent thinkers in the past abandoned the few solid facts they possessed. They
held that the mind functioned in a manner different from that of the material
world and consequently they failed to enquire further. In contrast, modern
doctors see mind as a function of the brain. By the study of anatomy and
pathology they seek to discover its mechanism; information acquired by this
method will give Medicine a degree of certainty in mental illness which, until
now, has been notably lacking.
If physiology has not yet revealed the mechanism of mind, pathology has fared
little better in eliciting the cause of mental disturbance. However, the spirit of
man cannot tolerate uncertainty for long without seeking explanations, however
illusory. In an attempt to understand insanity, numerous fanciful theories have
been produced. Madness has been attributed to a fiery or malignant
indisposition of the spirit, to sinning matter or to an evil humour. In the
treatment of insanity mysterious compounds have been employed which
superstition decreed were sacred and whose mode of action should therefore not
be investigated. For example, Hellebore was said to have the property of
expelling atrabilious humours.
However, passing on from mans past confusion, I hope to present the current
state of medical knowledge about this important aspect of pathology. With
reference to mental disease in general, I will describe the history of acute mania,
which is the subject of my dissertation.
a

The footnotes were prepared by Paul Groussac (Toulouse 1848 - Buenos Aires 1929), historian,
writer, literary critic, intermediate teacher and Director of the National Library from 1885 until his
death. His works include Amparo, a novel (1909), El viaje intelectual (1904), Mendoza y Garay, 2 vols.
, 10 vols. (1900-1915). J. L. Borges said of him, He would have wished to
(1916), Anales de la Biblioteca
be famous in his country and in his native tongue, but he became so in a language which he had mastered
but which never satisfied him completely, and in distant regions which were always an exile for him. His
true task was to teach French rigour and irony to a continent in its infancy. (J. L. Borges, Prólogo in
P. Groussac, Crítica literaria
, Barcelona, 1987).

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212

first regularly treated in England. An empirical approach


there was, as yet, no body of work describing the many
but
guided therapy,
different types of mental disturbances. Dr Perfect described a variety of cases of
mental disturbance and to each he assigned a cause.2Greding in Germany
adopted the approach most favoured at the time: he observed the symptoms
during a patients lifetime and sought to establish the underlying structural
lesion responsible for the
He did not achieve this, but this could not be
the work of just one man.3
M. Pinel in France made an important contribution in describing the variety
of mental symptoms.4 He collected clinical information from colleagues who had
experience in the field. As the senior doctor in the Bic6tre and Salpetriere
Hospitals for many years, he was in a position to observe the manifold varieties
of mania, the influence of moral treatment and the effect of an orderly routine on
the patients. He provided a great service to science and humanity by improving
the treatment of maniacs and releasing them from the empiricists who had
regarded them as wild criminals to be tied down with fetters and beaten,
regardless of their feelings. These cruel people enjoyed the suffering of the
mentally disturbed and avoided anything that might have alleviated their
desperate state. Anyone unfortunate enough to enter one of these forbidding
institutions was considered to be incurable. M. Pinel established the importance
of moral treatment, but did he exploit all the advantages of his situation? I do not
think he did. Apparently, he used his observations only to develop a nosographic
framework for mental disorders, while considering that it was useless to
investigate the underlying organic disturbance. He criticized Greding for
searching for organic changes in the brain, cerebellum, meninges and the bones
of the cranium, because he believed it was impossible to establish a relationship
between the physical appearances manifested after death and the mental
disturbances observed during life. Indeed the contemporary state of science did
not establish this relationship, but if he had carried out autopsies on his patients,
would the information obtained not have proved illuminating? Consider how
Maniacs

were

disease.

2
William Perfect (1740-1789) was the author of numerous scientific and literary works; the
reference here is probably to that called Annals of Insanity (London, 1801), which has been translated.
He was not a pioneer, even in England; prior to him, Cullen had extracted his neuropathology doctrine
from the theories of Hoffman and Haller on the nervous system and irritability.
3
Alcorta exaggerates greatly the scientific importance of Greding (1718-1775), who deserves to be
considered only as a precursor of the somatic school (as opposed to the psychiatric based exclusively
on
thanks to his prolix autopsies in the Waldheim hospice which he directed.
4
Pinel (1745-1826) was a true sage and his knowledge of comparative pathology enabled him at the
onset of his career to challenge Cuvier in the examinations for a Chair in the Museum. His Medicalphilosophical treatise on mental disturbance is based principally, as the title would indicate, on
psychological considerations, and the reformer left the clinical side behind. In his masterpiece,
Nosographia, he applied Condillacs geometric analysis to matters which did not strictly admit this and
he suffered the passionate onslaught of Broussais. Alcorta repeats these criticisms, some of which are
well-founded, though not that of having neglected pathological anatomy. Bichat, in the Preface to his
Treatise on Membranes, recognizes that he owes Pinel the basic idea, set out in the Nosographia, that the
base for the location of disease must be sought in the tissues.

psychology),

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213
M. Pinel would have advanced this aspect of pathology if he had dedicated
himself to pathological anatomy! Perhaps his different categories would be no
more than the different aspects of a single condition.
We must isolate objects in order to know them well.~5 Hence the need for a
classification of mental disease. If this cannot be based on the underlying organic
changes, because they are not known, it must be based on the symptoms of
mental disturbance. In my opinion, M. Pinel deserves credit for his delineation
of four different classes of mental disturbance - mania, melancholia, dementia
and idiotism - each of which can present in many different ways.
Mania, the most common mental disturbance, demands particular attention. I
will concern myself exclusively with it and, in particular, with its acute form. I
will describe its known causes, features and treatment.
The causes of mania are so varied that they sometimes conflict and they have
no relation with the illness they produce. Entirely opposite causes produce a
single disturbance while a single cause gives rise to completely different
phenomena. Any excessively powerful physical or spiritual shock may cause
mania but only in cases where an individual is predisposed either by heredity or
by education, life-style, age or gender. Everyone who has written about mania
has stressed the aetiological role of heredity and observed that the disease is
transmitted from family to family in one generation.6 However, I think that less
weight should be given to this view: too often an hereditary predisposition has
been confused with the consequences of an imperfect education. In the first two
stages of life, everything is new, impressions are lasting: they decide the
character of the individual. If misdirected, they lead to certain erroneous
judgements which are not erased, and which mould the affective faculties. The
result is mental disturbance. A romantic education which prematurely develops
the imagination predisposes an individual to exaggerate everything and lose sight
of reality. This represents an early stage of mania. Just as mans physical system
requires balance, so too does his spiritual nature, where there must be the even
development of his intellectual faculties. Because education plays an important
role in this process it must be regarded as the most significant cause which
predisposes to mania.
The different periods of life are accompanied by the individual development
of the intellectual faculties and particular emotions are also prominent at each
stage of physical maturation. Youth, the prisoner of the imagination, discovers
5

Alcorta takes this well-known axiom of Condillac from

Pinel; it is repeated in

the

philosophy

course.
6
This would appear to be a lapsus calami for from generation to generation in a family. I consider
the doctrine developed in this paragraph highly debatable. There is no doubt that hereditary
predisposition dominates the etiology of the illness. As to education, in the great majority of cases, this is
public, that is, uniform for an entire social class, and it cannot be a direct factor; the most that can be
said is that education, disproportionate to the capacity of some individuals or their future social action,
usually creates circumstances and conflicts which are a crude test of mental balance. We have already
pointed in the philosophy course to these Condillacquian exaggerations of the power of education.

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214

love and religion and consequently lives in a new world created by fantasy.
During this stage mania is caused by excessive emotional responses to trivial
events. There are certain stages in female development when women are often
more vulnerable, and when even the slightest emotion may produce profound
changes in their mental faculties, e.g. puberty, pregnancy, birth and the
menopause. In general, individuals of either sex who have a lively imagination,
great sensitivity or who are susceptible to powerful passions are very predisposed
to mania.
The origins of mania lie with emotions of all types: they may be considered to
be equally the cause, the symptom and the means to curing the illness. There are
emotions which are so powerful that the faculties of understanding become
fixated with a single object and are thus impaired. If the emotions are simple,
they can be observed by certain obvious physical signs, such as spasmodic
muscle movements, occuring mainly in the face. They are discernible to anyone
trained in anatomy and have been portrayed by poets, painters and sculptors.
These are the most common causes of mania.
The history of this illness is filled with cases caused by habitual drunkenness,
suppression of a haemorrhage, cutaneous exanthema, gout, contusions, gastroenteritis and by all types of excess.
Features. Mania is characterized by a fairly generalized disturbance of the
faculties of understanding, accompanied by nervous excitation with or without
delusions. There are always exaggerated or furious movements. There are three
different stages, involving the acute or chronic phases.
Symptoms. In acute mania, all writers consider gastro-intestinal symptoms to
be prodromal. These affect the epigastric regions with a feeling of constriction,
a voracious appetite, disgust at food, intestinal pain leading to a desire for cold
drinks, and persistent constipation. This is quickly followed by disturbed
thoughts which find their reflection in exaggerated gestures and meaningless
movements. Thus it would seem that this condition originates in the stomach,
from where it spreads to the brain by a type of irradiation.~
A variety of premonitory symptoms are also seen, and these relate to the
content of the impending delusion: thus erotic mania begins with the nocturnal
appearance of the loved one, by ecstatic visions and by fits of maniac devotion.
Anything, even the vain products of the imagination, may form the content of
delusions in mania.
In the first stage, mania is distinguished very easily from other mental
conditions by extreme variations in sensitivity; by the occasionally excessive
development of body heat and by the increased ability to bear fierce cold;~by
lack of sleep; by alternating increased appetite and disgust for food, sometimes
7
In literally reproducing this view of Pinel (
Nosographia II, p. 100), which is at least exaggerated,
Alcorta takes it even further, suppressing the masters prudent extenuation: doivent faire présumer
que le siège primitif en est presque toujours, etc..
8
Along with modern monographs, Pinel opposes this very generalized opinion, as too absolute.

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215
with the firm intention of starving oneself to death. This stage is also recognized
by striking changes in the colour and features of the physiognomy. There is
generally an extreme sensitivity of the sense organs, chiefly those of sight and
hearing. There is a rapid succession and a great confusion of ideas; sometimes all
the faculties of understanding are disrupted, but at other times just one or two.
Memory may be impaired during the first stage of mania; or it may be preserved
and even improved to the point of recalling childhood games. The most common
type of mania is where understanding is untouched but judgement is impaired.
When judgement is faulty, the wrong conclusions are drawn. How easy it is to
link two unconnected ideas, and to how many excesses does an error of
judgement not lead us! This is why the unfortunates whose reasoning is
disturbed deserve our compassion. An old soldier of the Motherland believed
that the Holy Spirit had given him the commission of destroying all women. He
produced a dagger and the first woman he met fell victim to his bloody mania.
The imagination plays an important role in this illness: although disturbed it is
almost always significantly exalted.
In hospitals it is very common to see certain manias called reasoned manias,
where there is no impairment in reasoning but where irregular movements,
inappropriate passions and certain physical and spiritual disturbances point to

illness.9

The moral character of individuals usually undergoes an extraordinary


change. Men of the most refined habits are given over to the most foolish acts of
corruption and immorality.
When mania reaches its most extreme stage, there is a complete disruption of
ideas, a total lack of judgement and bizarre, exaggerated and irrational emotions.
The period of recovery and convalescence possesses its own distinctive
features. It is marked by a gradual disappearance of symptoms: ideas follow one
another more calmly and with less frenzy; gestures are less expressive but more
natural; obstacles are suffered patiently and gradually reason returns.
Maniacs during this period desire to be with their relations and to return to
their former activities. In general they are sad and taciturn: they seek to be alone
and try to avoid the gaze of those who have helped them. As if fearing that they
will become disturbed again, they become more amenable and it is then that they
find their spouses more tender, their parents more loving, and their children
obedient.
This occurs when the illness is on the point of endangering physical health. At
this stage the illness can remit, become chronic or culminate in a fatal disease.
Apoplexy and dementia are its most frequent results when it is not properly

more

Pinels reasoned mania, that without delusions, is one of the most debated questions of mental
writers confuse it with lucid insanity (Trelat) or moral insanity (Prichard). Others,
more radical, such as Falret and Griesinger, deny that there can be mania without delusions. In this case,
what is understood by maniac delusion must be defined.

pathology. Some

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216

treated or the cause is not removed. Mania often ends with epistaxis,
haemorrhoidal bleeding or menorrhagia. The same result occurs in several skin
conditions and in diseases of the internal organs. There is a well-known case in
the Hospital of a maniac who had suffered from a rheumatic condition for a long
time. It suddenly disappeared and he was not heard to utter a word and he did
not move for a period of two years. An inflammatory swelling had spontaneously
appeared in the abdominal region, which countered the cause of the mania,
resulting in its disappearance. These beneficial consequences of nature or
science throw some light on the state of the brain in mania and give a clue as to
its possible treatment.
Mania is more frequently cured than other types of mental disease. 10 In
general, however, its prognosis is very difficult to determine: in most cases the
doctor cannot anticipate the factors which may prolong it and make it incurable.
The prognosis is based on: the nature of the cause; the content of the
accompanying delusion; and the duration of the illness.
In the treatment of no other disease does the doctor have such a need of
philosophy as he does in mania. How well he needs to know a mans heart, his
mode of being and of feeling. How important are feelings in bringing about
recovery! And how heavily must the doctor-cum-philosopher rely on his own
strengths to deal with the infinite variety of human vulnerability! Forced to treat
patients, who are generally not docile, it is an enlightened doctor who will only
order strict measures when needed and order gentle measures without showing
weakness. It is this particular skill which forms the basis of moral treatment.
Treatment differs in the three stages of mania. In the first stage, all the
symptoms point to a particular excitation of the brain, with agitation, vague
preoccupations, panic, terror, a constant state of insomnia and an increase in
body heat and muscular strength. The eyes flash, the thirst is intense and
everything indicates that the doctor cannot be a detached and passive spectator
during this stage.
All writers have observed that gastrointestinal symptoms precede mania in the
majority of cases. Since this was noted at a time when mania was only poorly
understood, why was priority not given to examining the gastric organs, which
were held to be of the utmost significance in all diseases?
It is necessary to avoid stimulating bodily
as they are all linked to the
brain. The patient must be deprived of light.Food must be limited and easily
digestible; just as the passions stimulate the brain, so does food effect the
stomach. The patient must be removed from anything which may excite him.
General bleeding should be performed when there is increased excitation of the

systems

10

It is generally agreed that, in simple idiopathic mania, two thirds of cases are cured.
I do not think that this prescription of Pinel (
., 112) continues to exist today: on the other
op. cit
hand, he did reserve it for the acute state and with very intense symptoms: the same would be said of
bleeding, so much abused in former times.
11

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circulatory system. If this is not appropriate, local bleeding should be applied.


When it is considered that the irritation of the brain is reduced, revulsives may
be used, externally on the skin and internally to the intestinal canal, providing it
is not the original site of the disease. If it is, cool drinks should be given in
abundance. The different causes of mania will determine the treatment. Thus
when a suspension of haemorrhoidal flow leads to mania, leeches should be
applied for twelve months; in cases of amenorrhagia, leeches should be applied
to the vagina. Caustics should be applied to inflamed skin conditions.
By the second stage the doctor must wait for nature to take its course, and do
nothing more that treat the persistent constipation that usually occurs at this
point. This is the crucial stage in the illness and moral treatment is paramount.12
The brain is very vulnerable if it is too powerfully stimulated. The patient must
be gradually removed from the isolation in which he had to be placed during the
initial period and slowly returned to his former activities. However, this
requires particular judgement in order to avoid a relapse. Careful management of
the maniacs mental faculties can result in therapeutic success. High spirits with
lability of emotions and confusion of the senses should be subdued. The patient
should be presented with new activities and his attention directed towards novel
experiences. One has to know when to counter the passions and when to
accommodate them, without appearing either tyrannical or weak.
Hygienic treatment is useful in the convalescent period. Music has always
been seen as a potent means of treating mania and anything which distracts the
patient is helpful. Physical exercise is particularly efficacious - riding, fencing or
travel. The patients physical environment including his clothing and his food
must be designed to strengthen his weakened reason.
In this country, mental disease is characterized by depression rather than by
the excitation of acute mania. In fact, in the last four months there have been
only three cases of acute mania in this hospital and they have responded to
treatment. The study of pathological anatomy is important in acute mania,
although there is a lack of consensus as to the precise changes in the brain in
this condition

12
These ideas of Pinel have aged: the maniac is not susceptible of moral treatment except in
convalescence.
13
After seventy-odd years and notwithstanding the hundreds of opinions issued, it would not seem
that the agreement hoped for by Alcorta has occurred.

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