1991 - alcorda diego - disetacion en mania aguda

8/19/2019 1991 - Alcorda Diego - Disetacion en Mania Aguda

http://slidepdf.com/reader/full/1991-alcorda-diego-disetacion-en-mania-aguda 1/8



DIEGO ALCORTA

(University of Buenos Aires, 26 June 1827)

Dissertation on acute mania1

The mind ofman has always been of the greatest interest to the philosopher: as

a unique attribute of the human species, it has inevitably demanded explanation.In the absence of clear information, from which to draw logical conclusions,eminent thinkers in the past abandoned the few solid facts they possessed. Theyheld 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 malignantindisposition 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 man’s 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 ofmy dissertation.

1 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 hisdeath. His works include Amparo, a novel (1909), El viaje intelectual (1904), Mendoza y Garay, 2 vols.

(1916), Anales de la Biblioteca, 10 vols. (1900-1915). J. L. Borges said of him, ’He would have wished to

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. Histrue task was to teach French rigour and irony to a continent in its infancy.’ (J. L. Borges, ’Prólogo’ inP. Groussac, Crítica literaria, Barcelona, 1987).

by Fernando Ferrari on September 23, 2008http://hpy.sagepub.comDownloaded from

http://hpy.sagepub.com/






212

Maniacs were first regularly treated in England. An empirical approachguided therapy, but there was, as yet, no body of work describing the many

different types of mental disturbances. Dr Perfect described a variety of cases ofmental disturbance and to each he assigned a cause.2Greding in Germanyadopted the approach most favoured at the time: he observed the symptoms

during a patient’s lifetime and sought to establish the underlying structural

lesion responsible for thedisease. He did not achieve this, but this could not be

the work of just one man.3M. 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 SalpetriereHospitals 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 onthe patients. He provided a great service to science and humanity by improvingthe 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 forbiddinginstitutions was considered to be incurable. M. Pinel established the importanceof 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 itwas

useless toinvestigate 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 relationshipbetween 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

2William 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 exclusivelyon psychology), thanks to his prolix autopsies in the Waldheim hospice which he directed.

4Pinel (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 Medical-

philosophical 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 Condillac’s geometric analysis to matters which did not strictly admit this andhe 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 heowes

Pinel the basic idea, set out in the Nosographia, that thebase for the location of disease must be sought in the tissues.








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.5We must isolate objects in order to know them well.~ Hence the need for a

classification of mental disease. If this cannot be based on the underlying organicchanges, 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 haveno 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 thecharacter 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 developsthe imagination predisposes an individual to exaggerate everything and lose sightof reality. This represents an early stage of mania. Just as man’s 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 importantrole 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 developmentof 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 hereditarypredisposition 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 alreadypointed in the philosophy course to these Condillacquian exaggerations of the power of education.








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 oftenmore vulnerable, and when even the slightest emotion may produce profoundchanges 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 predisposedto 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 spasmodicmuscle movements, occuring mainly in the face. They are discernible to anyonetrained 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, gastro-enteritis 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 meaninglessmovements. 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;~bylack of sleep; by alternating increased appetite and disgust for food, sometimes

7In literally reproducing this view of Pinel(Nosographia II, p. 100), which is at least exaggerated,

Alcorta takes it even further, suppressing the master’s prudent extenuation: ’doivent faire présumerque le siège primitif en est presque toujours, etc.’.

8 Along with modern monographs, Pinel opposes this very generalized opinion, as too absolute.








215

with the firm intention of starving oneself to death. This stage is also recognizedby striking changes in the colour and features of the physiognomy. There is

generally an extreme sensitivity of the sense organs, chiefly those of sight andhearing. 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 preservedand 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. Heproduced 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.9The moral character of individuals usually undergoes an extraordinary

change. Men of the most refined habits are given over to the most foolish acts of

corruptionand

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 theywill 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

more 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

9Pinel’s reasoned mania, that without delusions, is one of the most debated questions of mental

pathology. Some writers confuse it with lucid insanity (Trelat) or moral insanity (Prichard). Others,more radical, such as Falret and

Griesinger, denythat there can be mania without delusions. In this case,

what is understood by maniac delusion must be defined.








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 inthe Hospital of a maniac who had suffered from a rheumatic condition for a longtime. 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 spontaneouslyappeared 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

doctorcannot

anticipate the factorswhich

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 man’s 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 ofhuman vulnerability! Forced to treat

patients, who are generally not docile, it is an enlightened doctor who will onlyorder strict measures when needed and order gentle measures without showingweakness. It is this

particularskill 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 poorlyunderstood, why was priority not given to examining the gastric organs, whichwere held to be of the utmost significance in all diseases?

It is necessary to avoid stimulating bodily systemsas they are all linked to the

brain. The patient must be deprived of light.Food must be limited and easilydigestible; 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

10It is generally agreed that, in simple idiopathic mania, two thirds of cases are cured.

11I do not think that this prescription of Pinel(op. cit., 112) continues to exist today: on the other

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.








217

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 itis 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 appliedto 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.12The 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 theinitial period and slowly returned to his former activities. However, this

requires particular judgement in order to avoid a relapse. Careful management of

the maniac’s mental faculties can result in therapeutic success. High spirits withlability of emotions and confusion of the senses should be subdued. The patientshould 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 alwaysbeen seen as a potent means of treating mania and anything which distracts the

patientis

helpful. Physicalexercise is

particularlyefficacious -

riding, fencingor

travel. The patient’s 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 bythe 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

12These ideas of Pinel have aged: the maniac is not susceptible of moral treatment except in

convalescence.13 After

seventy-odd yearsand

notwithstandingthe hundreds of

opinions issued,it would not seem

that the agreement hoped for by Alcorta has occurred.






1991 - alcorda diego - disetacion en mania aguda

Documents