are quite sufficient to explain, not only the impairment of memory, as already indicated, but also that of self-control and judgment, both of which are generally present in mania.

Clearly defined and fixed delusions are rarely present in acute maniacal excitement. Indeed, they would be quite inconsistent with this character of mental activity. The vitiated quality of thought consists rather in the ideas which do not remain in the field of consciousness long enough to become beliefs of any kind, and generally not long enough to become correct ideas. In the condition of the nerve centres incident to this state, as above explained, the irritations which impinge upon the organs of sense, or the nerves of sensation, flash through the nerve-channels, leaving only the faintest impressions, and, consequently, give rise only to simple fragments of ideas, which are equally transitory. A belief, therefore, whether true or false, can hardly be supposed to be developed anew, and only such ones present themselves temporarily in consciousness as may have been formed in it while in a previous condition of health, and the memory of which may come into consciousness for the time being.

The supersensitive condition of the brain centres. and the increased amount of blood present in the vessels of the brain give rise to wrong impressions, which, in their turn, generally give rise to equally false views concerning persons and things; a movement on the part of an attendant, a word, an inflection or tone of the voice in speaking, is misinterpreted simply because of the rapid flow of other half-formed concepts. And each new excitation causes a new crowd of images and delirious concepts to arise, which do not remain long enough to become crystallized into any quality of belief. This, however, is not true in cases in which

the degree of excitement does not become so pronounced, and in which there appears a degree of method in conduct and coherence in ideas.

Delusions of a transitory character are not uncommon in such cases, the patient feeling that he is a person of the largest importance, that he has filled positions of authority and influence in the past, and is now incarcerated simply to deprive him of his rights. A young man came under my care formerly, who had been engaged as a book-agent, and had been fairly successful. While attending some religious meeting, he became impressed with the belief that he ought to become a preacher, and, soon after that, he actually had become one. He prepared and delivered several sermons in a school-house, to willing hearers, but soon after became so much excited that he was brought to the Retreat. This movement on the part of his friends he resented very stoutly, declaring that he had letters of the highest commendation in his pockets in relation to his ministerial abilities, and that to take him away, just as he was thus engaged in preaching one of the greatest sermons ever preached in the State, was an outrage which should be punished in the severest manner. This delusion, however, remained but a short time, and gave way to others equally transient in character, and he soon passed over into the condition of excitement in which nearly all sequence of ideas was lost, while his mind went stumbling on from one to another with the greatest irregularity.

In chronic and special forms of mania, the false conceptions and dominant ideas generally pass over into defined delusions with greater or less intensity and duration.

The course and progress of acute mania vary very largely in different cases, even when there may exist no apparent assignable cause for such variation. The maniacal

condition may continue for a few weeks only, or it may extend over a period of months. A stage of continuous mental excitement with restlessness and large increase of motor activity may be continuous, or the excitement may subside for short periods to be again renewed. In such cases there is no real remission, but simply a diminution, for the time being, of the intensity of the mental and physical activities. The length of time, however, during which such remissions may continue, and also the degree of remission, will greatly vary in different cases, and, in some, may continue for several months. A female patient formerly in the Retreat experienced as many as thirty of these remissions within a few years, during which she could reside with her family. In such cases a true neurosis becomes established.

These exacerbations may assume a true remittent type, the patient being excited on alternate days or on every third day. It has occurred to me to observe only three such cases, two of them being under my own care. The cause of these regular remissions was not apparent; it certainly did not appear to be of malarial origin, so far as ascertained. Quinine was used freely, but produced no effect in checking their appearance, though they ceased after the long-continued use of arsenic. Whether this was due to the effect of the drug, or to the fact that the course of the disease naturally terminated, is not clear.

It is commonly observed that when the menstrual flow continues monthly during an attack of mania, its presence is attended with an increase of mental and motor excitement.

It has often been observed that the symptoms of other forms of disease which may have existed during months or years may largely or entirely subside during an attack of mania.

This is especially noticeable in cases of phthisis. A young lady was recently in the Retreat during an attack of acute mania, from which she made a most happy recovery, who, when admitted, was suffering from a severe cough, and had experienced several hemorrhages from the lungs. In her case the degree of excitement was less intense than is sometimes observed, but still was very considerable, and extended over a period of several months. After the first six weeks the appetite became very keen, and she took large quantities of food; the cough entirely disappeared, and she gained, during the progress of the disorder, more than fifteen pounds in weight. It is not to be inferred, however, that there was a return of healthy tissue in the lungs to any considerable degree, but only that the objective indications and former progressive development had been checked by means of changes in the circulation and in the quantity of nerve energy present. Such modifications of symptoms sometimes occur, for short periods only, in typical cases of phthisical insanity.

Again, the progress of the disorder may sometimes be arrested and cut short by the appearance of some other form of disease, such as a carbuncle, or several boils, or an attack of intermittent fever, or again, by profound impressions made upon the nervous system through the occurrence of accidental injuries. Such effects would appear to be allied to those sought to be produced a century or less ago by plunging patients into baths unexpectedly, or by submerging them under water until partially suffocated.

An ingenious arrangement for this purpose existed in one of the oldest institutions for the insane in America, by means of which the patient, securely fastened into a chair, was lifted and rotated about by machinery until over a large tank of water, and was then suddenly let down into.

it, where he remained during the pleasure of the operator. The operation could be repeated as many times on any occasion and as frequently as prescribed by the physician, and to the heart's content of the attendant in case the physician did not choose to superintend the administration of his own prescription.

Some cases of violent mania may be arrested by the effects of a counter-irritation applied to the head, or nape of the neck, or to both, in the form of a blister, which should be large enough to create a condition attended with inflammatory fever. Also occasionally by the prolonged use of hot baths, during the administration of which cold applications are made to the head. It should, however, be remembered that such remedial measures are successful in a very few cases only, so few, indeed, as to be regarded as exceptional ones.

Termination.-Acute mania may terminate in any one of several ways. First, in recovery. When this is the case, the excitement generally becomes less; the attention can be more easily secured, and for longer periods; the patient responds more readily and intelligently to inquiries addressed to him. He begins to pass longer periods in a sitting posture and sleeps more hours, and with less of medicine to induce sleep. As he begins to come to himself and realize that he has been ill, and is now in unusual conditions, he becomes less inclined to talk, and avoids alluding to his past condition, and may, when alone, seem to be slightly depressed. When the excitement has been intense, he has no idea as to the period of time passed since he was brought to the asylum, and may have no recollection of coming. The transition to a state of health may occur within a short time, or it may be very gradual, and extend over several weeks, and even months, before the mind