The maniacal symptoms really, then, form a second stage in the attack, in which the symptoms have extended to the intellect, so that all the three divisions of mind are involved at the same time.

With respect to the emotional symptoms, there is often a strange mixture of hilarity, depression and grief; the instinctive feelings and sense of propriety, of personal cleanliness, are impaired or lost; the patient appears at times indifferent to the most disgusting objects; some become filthy in the extreme; pass their fæces in their room or bed, and begrime themselves from head to foot with it; and this appears to be almost a peculiar propensity-a very symptom of the disease

so many do it; they will eat dirt, filth, and the most disgusting matter; they are totally unmindful of decency, but not apparently with any lewd intent, but from an apparent loss of the normal feeling on the subject. Educated females, men of refined minds, become the unfortunate subjects of these abnormal propensities.

The delirium in mania has more the character of frolic and boisterous excitement; there is not, in the acute stage, the scowling of the resentful madman, but rather a violence of muscular, motor irritability. Maniacal patients are not necessarily irascible. They run, dance, jump, throw themselves down, shout, scream, and consequently are nearly always hoarse; they tear off their clothes, and go about in a condition of the greatest disorder of dress-their shoes off, their stockings down, their hair rough, dishevelled; they will strike, perhaps, if opposed, or if provoked.

With regard to the intellectual faculties. Their ideas roam, and follow each other rapidly and in the greatest disorder. The maniacal will answer, but speedily ramble again from the point; their talking is so rapid, so various, that it is often difficult to ascertain the existence of actual delusion; they cannot be made to attend sufficiently long to the questions put to them. But certainly the character of the mind appears less altered by true delusion than by delirium or a state of general excitement. The ideas follow in too rapid succession; but I cannot say that I have ever been struck with the eloquence of the maniacal patient, or with the loftiness or imaginative character of their thoughts. The expressions are more like a

confused mêlée, and amount to a simple volubility, totally uncontrolled. In the acute stage, i. e., in an acute case of mania, the intellect is therefore considerably disturbed, as well as the motility, as shown by the very constant motion and restlessness; but true delusion is not necessarily present-that symptom is more usually associated with insanity in its chronic form.

Headache is not often complained of in the acute stage, and there is seldom, as a rule, any appearance of paralysis, strabismus or convulsion. The pupils usually are equal, but may be contracted or, less frequently, dilated; there is photophobia and intolerance of noise in some cases.

The facial expression in mania differs much in different cases. In melancholy the face indexes the mind pretty accurately, but in mania the extravagance of the ideas, the mixture of anger, grief, gratitude, and resentment, alternate so quickly that it is most difficult to describe any form as the fixed expression. There is, however, a wildness of glance, which is heightened in its effect by the general disorder of the dress and hair, and not infrequently by the dirt.

The health is interfered with in mania by the want of sleep, which is very common, for the patient shouts and screams or sings very frequently night and day. The digestive organs appear to suffer, and seemingly from the quantity of filth and dirt which the patient eats; and the filth in which he delights to wallow of course renders him the more liable to a generally impaired condition of system.

It is very common for the subject of mania to be affected with boils. The appearance of these has been looked upon as critical. I think, rather, that they have more connection with the dirt and filth which the maniacal eat, and the foul state of skin which they induce by their habits. The skin is often dry, and it has been universally asserted that the maniacal and insane generally emit a peculiar odour from their skin. It may be so, yet there is much to prevent an accurate investigation of this. Undoubtedly, there is often a peculiar odour in asylums; whether the odour, which is of an ammoniacal character, comes from the skin or the clothes, that is from the urine, I have never been able to satisfy myself. In most cases the hair is also altered; it becomes dry and rough. There is often a propensity in the patient to pick it out by the roots, so that bald patches are

caused; when this occurs it is probably due to some irritation or heat felt by the patient. I have been frequently induced to have the hair removed in such cases by the razor; this helps to cool the head, and, at least for a while, cures the propensity, which is apt to become a permanent trick. It is very common for the maniacal to put their head into cold water, or place it under the cold-water tap, indicating some indescribable heat probably within the head, for true headache is not often complained of.

The respiratory organs are not usually affected in typical cases. Cases of mania, however, occur in phthisical persons; the phthisis I look upon as non-essential; the heart's action and pulse are not necessarily altered, apparently.

The urine in mania undergoes changes according to the presence or absence of paroxysms. Sexual functions are most frequently, in my opinion, normal; menstruation often is normal. There is usually absence of sexual excitement in acute mania.

Besides the occasional occurrence of boils, there are certain other symptoms which have been enumerated as critical: I should, however, simply call them signs of convalescence; such as the re-establishment of menstruation, when that secretion has been suppressed, and which is by no means frequently the case : or the setting in of diarrhoea; but this occurs, as it were, by accident, it is not so frequently observed as to be expected in any instance. Without denying that there are certain crises in the course of mania, I am not satisfied that it is yet known at what periods such may be looked for.

The acute form of insanity terminates most frequently about the third month, or from that to six months, but many cases run on to one or two years and ultimately recover; and when the disease has passed the third month, and the melancholic symptoms have continued through that period, the accession of a maniacal condition is to be considered favorable rather than the

reverse.

When the progress is favorable the disease subsides very gradually in most cases of mania; there is a return of a more natural expression of feature, an inclination to order in dress and conduct; often the patient, at the same time, gains flesh rapidly, and there is an admission, on the part of the patient, of his past insane condition.

We have thus traced the mental disease through its second epoch, or in which the case, commencing by a melancholic stage, without actually becoming chronic, passes into a new phase by the evolution of maniacal symptoms; and I have described to you how the melancholic and maniacal symptoms blend in different cases, some cases becoming half melancholic and half maniacal, and others purely maniacal; we will proceed, in the next place, to the consideration of the disease when it has passed into a state of chronicity, or, in other words, to the description of chronic insanity, which subject we will enter upon at our next meeting.

LECTURE IV.

Argument.-Chronic Insanity-Multiplication of names chiefly connected with this condition-Classification of so-called varieties: 1. Cases named from a prominent symptom; 2. Cases named from the supposed cause; 3. Names based on the phenomena of different stages-The character of chronic insanity, chiefly connected with the intellect proper-Cases in illustration-Folie circulaire-Folie à double forme.

I stated in my previous lecture that the progress of a case of insanity must be in one of the following ways:1. Towards recovery. 2. To a further development of the acute symptoms. 3. To a state of chronicity. Or, 4. Towards death. We have already considered the disease under the first and second heads; to-day I proceed to describe the disease when it has become chronic.

Insanity, when it has existed more than a year, may be, I suppose, justly called a chronic affection; but the precise time when a case is entitled to this appellation is, of course, a matter of great uncertainty; perhaps we should be more justified in estimating the state of chronicity by the activity of the symptoms. There is some difficulty in this mode also.

I have already pointed out that a case of mental disease, in its melancholic stage, at times continues so for years, the patient remaining constantly depressed; it would be difficult to fix a precise day when such a case should be called chronic and when the contrary.

By a state of chronic disease is therefore meant a condition where there is little or no change of the phenomena for some considerable time, as many months or a year.

When mental disease or insanity has arrived at this, I know of no better name for it than Chronic Insanity, or Chronic Mania, the latter term is that which is, perhaps, most frequently applied in this country to these cases in their purest form. The French employ the term Monomanie, and the German Verrucktheit, or Wahnsinn, for the same cases.