continuance of excitement which might rightly be regarded as abnormal in one person, would not be necessarily so regarded in another. There exist wide departures in these respects, at times, in every person, in either direction. The ever-varying conditions of the physical system have a large influence upon the brain, not only in respect to the amount of its function, but also in respect to its quality and its facility of action. Concentration of attention, continuity and perspicacity of thought, are greatly more difficult, and often retarded when certain bodily conditions of health exist, as compared with certain others in the same person. Different periods of life also greatly modify the character and quality of brain activities, especially in the female. There also exists a very wide range of difference in this respect among different nationalities. While, then, such changes in the ordinary conditions of mental activities are the first indications usually observed in cases of melancholia and mania, yet they are of little importance when considered by themselves, as other elements of change are always found to accompany them.

Having studied in the preceding lecture the morbid states of mind termed melancholia, with its large variety of departures from a normal standard, all of which represent conditions of depression combined with painful emotions and a self-consciousness which has become abnormal in character, united with an aversion toward, and even an incapacity for, physical exertion, we now turn toward its opposite-viz., mania. In this disorder the inhibitory centres are the first to become affected, and there exists an unusual freedom of action which manifests itself in the affective faculties rather than in the intellectual. The impulses become stronger and are less easily restrained, until there is established a more or less continuous excitement,

attended with an exaggerated self-confidence and an unusual energy of will.

The essential primary element, therefore, in maniacal conditions of the mind consists of some lesion of the emotional department of the brain which results in an increased quantity of psychical activity, and in a derangement and confusion of thought, attended at times with delusions and hallucinations, together with an increase of muscular activities of various kinds. Whether the development of the maniacal state is the result of an extension of the morbid condition of the brain which nearly always precedes it, i. e., that of depression; or whether it be due to changes of another character, de novo in the brain; or, again, to the invasion of additional nerve-centres, is not easy to be determined. The latter view is more probably the correct one.

It is important to bear in mind that such increase of mental action and restless motor activity are not confined to cases of acute mania. A derangement of emotional energy, similar to that which arises from the presence of delusions and hallucinations, is sometimes present in cases in which there exists a profound failure of the mental faculties. The same is true, at times, in acute inflammation of the meninges of the brain in delirium tremens and in typhoid fever.

Definition.-Mania may be defined as consisting in a morbid excitement of the affective faculties, which discloses itself not only in a prolonged increase of psychical functions, but also in increased muscular activities, impairment of judgment and self-control, with change of character.

Etiology.-Profound moral impressions, physical ill health, reverses in fortune, loss of property, disappointment in love, seduction and abandonment, and, in short, such

experiences as deeply affect the emotional faculties of the mind. In the large majority of cases however, there exists back of these exciting causes the predisposing one, viz., an unstable constitution of brain structure, which may have been inherited from parents or grandparents, or may have been the result of former ill-health, or the practice of vicious habits of life.

Mode of Invasion.-In the large majority of cases the condition of maniacal excitement is preceded by one of depression. It is afterward remembered that during several weeks or months, the patient has exhibited a change in his feelings and character; his likes and dislikes; has been moody and fitful, irritable, has not slept well, and has complained that something was wrong. This is gradually succeeded by nervousness, restlessness, discontent, talking to himself, and in some cases by hallucinations of hearing. Those who have passed through one or more attacks of mania, generally recognize these indications, and not unfrequently declare the belief that they are again to become insane.

According to some authors, some such incubative stage of melancholia (stadium melancholicum) nearly always precedes the development of mania, and may come to be regarded as constituting a part of the symptoms. But there can be no doubt that the disorder arises in some cases with no antecedent conditions of depression sufficiently well marked to have attracted the attention of friends or physicians. It may arise in this manner from sudden fear, moral injury, excess in the use of alcohol, and from the practice of venery. It announces itself at once by marked physical and mental excitement. In such cases there may have been some pain in the head, and inability to sleep as much as usual. The latter symptom is one of the most

persistent, and generally one of the last to disappear. Sometimes cases are ushered in by a stage of more or less febrile excitement, with loss of appetite, loathing of food, and increase of temperature, unpleasant dreams, loss of flesh, constipation, and abnormal sensations, etc. These conditions, however, pass away as the disease declares itself, and the patient becomes abnormally insensible to his surroundings and experiences.

Physical Symptoms.-The contrast between the physical conditions present in mania and those existing in melancholia is certainly most marked, and when the disorder has become fully pronounced, becomes especially apparent in the countenance and the whole bearing of the patient. The physiognomy, instead of being pinched and thinner than in health, becomes fuller; the capillary circulation is increased; the eyes become brighter, more expressive, have an increased freedom of movement, and, at times, under the influence of excitement, are protruding; the pupils are, in some cases, contracted, and in others dilated, and, in the same case may vary from day to day, and even from one part of a day to another; they appear to be more sensitive to the presence of light than in health, especially in the carly period of the disease. The body becomes more erect and assertive when walking or standing, the patient becomes careless as to personal appearance, and the dress is disordered; the hair unbrushed, and, in some cases, dry and stiff; the voice is pitched in a higher key, and the words flow rapidly and freely, and are attended with gesticulations of the body, arms, and hands; the tongue is usually coated in the early stages of the disease, and the skin is dry, unless in exceptional cases in which there may exist a most disagreeable odor.

In connection with these physical changes, there is another

which is one of the most prominent in cases of acute mania, viz., an increase in muscular movements. This is especially observable in that portion of the muscular system which is under the control of the will; the patient rarely remains quiet, or in one position longer than a few minutes at a time; he is on the move, and all movements appear to be executed with the greatest ease and freedom, and without apparent fatigue. The amount of this activity, which delicate females and aged persons are able to make while under the influence of maniacal excitement, is almost incredible; persons who have, for years, been accustomed to a sedentary life, and who are ordinarily, when in health, fatigued by walking a short distance, when under the stimulus of this excitement will pass days and nights during weeks with almost no rest for the muscular system or sleep for the brain. The demand of the system for rapid and energetic activity appears to be most imperative; this is merely the outward expression of the storm which is raging within. In some cases it expends itself in a harmless manner, as in dancing, running, singing, and shouting, while in others the movements, as in a paroxysm, become suddenly violent in the extreme, and expend themselves upon whatever first comes within reach, without reference to consequences to either persons or things. The patient neither rests himself, nor suffers those about him to rest.

This continued and excessive expenditure of physical energy, sometimes continuing for weeks, and even months, has been thought to indicate an increase of strength, as compared with that pertaining to a condition of health, but in reality there is no such actual increase; the explanation lies in the fact that the person has become partially anæsthetic, and, consequently, insensible to pain and fatigue; he can be controlled easily by an attendant who is of much