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If the whole history of such cases could be unraveled, it would be found that there had been going on for months derangements of the physical organs, as well as of the mental functions. They, however, rarely come under the observation of the physician, and rarely have the slightest suspicion themselves that they require his advice for any purpose.

It should be remarked that as patients approach the period of convalescence, impressions of all kinds are stronger, more lasting, and leave an effect which can be readily recalled to remembrance; they may also be recounted afterward with more or less accuracy in words. Such patients can be influenced by associations with others, by changes in rooms and halls, by promises and incitements in the way of rewards, to exercise a larger degree of self-control, and not unfrequently, by such means, rapidly pass into a condition of convalescence.


MANIA (Concluded).

Review of Symptoms—Excitement-Artificial Excitement Produced by

Various Means—The Thought Process Modified by Changes in Blood Sup. ply and by Morbid Processes Affecting the Inhibitory Centres—Failure in Power of Attention- The Result of Imperfect Functionating of the Thought Process-Fixed Delusions are Rarely Present in Acute ManiaTransient Delusions May be Present-Course and Progress of Acute Mania-Exacerbations-May Assume a Remittent Type—The Symptoms of Other Forms of Disease May Become Modified During an Attack of Mania–Counter-Irritation--Terminations--First in Recovery-Danger of Relapses—May Pass into a Chronic State-Symptoms of Such a Condi. tion-Dementia-Excitement-Delusions—Table of Cases of Acute and Chronic Mania - Prognosis— Treatment-Importance of Sleep and Conservation of Physical Strength-Importance of Asylum TreatmentHydrobromate of Hyoscine—Bromide of Ammonium-Chloral— Paralde. hyde-Hot Baths-The Wet Pack-Out-of-door Exercise - Cannabis Indica-Quiet-Nourishment— Importance of Early Feeding.

In analyzing the symptoms which we have passed in review, we observe that the first and most conspicuous is that of excitement. This, in some degree, is an invariable attendant during the earlier stages of fully developed and pronounced cases. What is the physiological or pathological condition upon which it depends ?

In answering this question, it may aid us to refer to some causes of excitement acting upon other organs of the body than the brain. For example, we may produce an increase of heart action by the introduction of certain substances into

the blood, such as alcohol. The contact of this article, while in the blood, with the nerve filaments of the vasomotor system, which in health regulate the action of the heart, causes a partial paralysis, and this, indirectly, induces increased pulsation. A similar effect, though in a less degree, may result from other causes, such as an intense and continuous attention directed toward the action of the heart. In the former case there is produced a partial paralysis of the vaso-motor nerves, resulting indirectly in an increase of pulsation, and in the latter an increase of nerve-energy appears to pass directly into the motor system. In both cases a similar effect follows. This increase of function may continue within certain limits as to time and degree of intensity, without any consequent disease; but, beyond these limits, which vary in different cases, the action becomes excessive or irregular, and disease appears. The lesion consists in a disturbance of the normal balance existing between the two systems of nerves.

Now, excitement in that portion of the brain which is concerned in the evolution of thought may be produced in a like manner by the introduction of, for example, tea, coffee, or alcohol to the circulation. The presence of the ultimate particles of these substances in the blood, and acting upon the nerves of the blood vessels, causes them to dilate, which results in an increased flow of blood to the braincells. The presence of a sufficient quantity of properly aërated blood in the grey substance of the brain is essential at all times for the discharge of the thought function. A less amount than the normal supply slows the thoughtprocess and modifies its character, as shown in melancholia. The reverse is equally true; an increased amount of healthy blood in the brain (unless it becomes too great causes an increase in the product of thought. In a like manner,

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the continuous concentration of the attention on any special subject of thought, a profound grief or disappointment, a moral shock, all affect the thought-process by causing a more or less serious lesion of the inhibitory centres. The thought-process in health is largely automatic; thought of some quality comes whether we will or not; but while the two systems of nerves are properly counterbalanced as in health, the will may change the current of the thought, and modify its character to a greater or less extent. Now, in

, mania, the free exercise of the will power is invariably more or less impaired, and there can be no doubt that this is the result of a lesion of the inhibitory centres.

Mental concepts form and pass through the psychical circle of the brain with an abnormal rapidity and persistence for the time being. Within certain limits as to time and degree, no special harm may result; the action may be modified and controlled by the will, but when these limits are passed, the thought-process becomes persistent, morbidly excessive, irregular, and disordered, and we have the excitement of acute mania.

Another very common symptom present in conditions of acute mania is a failure in the power of attention. The extent of this lesion varies largely in different cases, as does the degree of increased excitement, but difficulty in fixing the attention, except for a very limited time, is a noticeable feature in most cases. If, for the time being, it has been secured, it may speedily become diverted by the most trivial incidents, such as the passing of a person, a distant sound, as of the human voice, or the song of a bird-in short, any occurrence or sound which may reach the ear.

Continued and fixed attention to courses of thought which may be passing through the brain, and, no less to external occurrences, is a prime requisite to insure an ability to recall them afterward. This is true in the case of the healthy brain. Very little of what may have passed before the eyes during a ride through the crowded streets of a strange city, or during the excitement of a prolonged battle, can be recalled with any degree of accuracy by even a strong mind, unless the attention has been fixed upon definite objects and occurrences at the time when observed. In either case a vastly greater number of persons and events pass before the eye than can ever again be recalled.

How much more true must it be as to what passes subjectively or objectively during the storm-period of an attack of maniacal excitement. Hence, nearly the whole period ever afterward seems a blank to those who have recovered from an attack of acute mania in which the excitement was very great.

Lesion of attention doubtless results largely from the rapidity and imperfect functionating of the thought-process, and the consequent evanescent character of impressions made upon the brain. The thought-images appear and vanish on the confused mental vision in such rapid succession and with such changing hues and colors as to preclude much effort to attend to them. The condition, therefore, is the legitimate outcome of the character of the brain action, and has been thought to depend upon the lack of balance, or of co-ordinating power in the different sections of the brain. If this means a derangement of the normal balance of nerve energy as between the two great systems of nerves, it is doubtless true. It has been suggested that the symptom of excitement itself may arise from this cause, and the lesion of attention may also do so in no less degree.

The two symptoms, excitement and lesion of attention,

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