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about the same time illusions and hallucinations begin to appear. The motor excitement, under which the patient invariably labors, is shown by his incessant movement and loquacity.

There are many varieties of mania described by different writers. First in importance is acute delirious mania. The features of this form are as striking as they are instructive. It runs a short and quick course, usually of from three to five days' duration, not oftener of more than ten days, seldom to recovery, most often to death. The chief symptoms are delirious incoherence of thought and conduct, taking on the form of a delirious frenzy. The frenzy is followed by a comatose exhaustion and collapse, in which the patient presents a dry tongue, feeble and irregular pulse, with lips and teeth covered with sordes. The temperature is high, ranging between 105° and 106°, continues unduly high throughout its course, and is high when a fatal end is near.

"Mania transition is an ephemeral aberration of mind of the exalted type, and of extremely sudden evolution."1 (After brief premonitory symptoms, such as vertigo or headache and suffused countenance, there is an outbreak of violent maniacal excitement, intense hallucinations, with confusion of ideas. The whole attack varies in duration from a few hours or days, and disappears as quickly. It terminates. by a long and profound sleep. All the symptoms of mania transitoria may be seen in the beginning of febrile and inflammatory complaints, in unstable brains, also in cases complicated by epilepsy.)

Under the head of "Periodical Insanity" we have intermittent and remittent mania and circular insanity. These are characterized by periodic departures from and returns to the normal mental standard.

Intermittent or recurrent mania is a form that is frequently seen in hospitals. The attack of mania, which is usually of the simple form, is of some months' duration, is followed by a period of perfect health on an average of a year or more. Then another attack of mania occurs, followed

1 Kellogg, Text-book of Mental Diseases, 1897.

by another interval of health. The periodicity may continue indefinitely or for a lifetime. Remittent mania differs from intermittent in the fact that the patient, during remission of all the symptoms, does not at any time return to the full level of mental health.

Circular insanity presents regularly attending and recurring periods of mental exaltation, depression, and sanity. The attacks of exaltation and depression succeed each other usually without any intermission, and are followed by a lucid interval of longer or shorter duration. The form of mania is usually of the type as described under simple mania.

The indefinite persistence of the symptoms of acute mania is considered as chronic mania. The excitement and exaltation is continuous, but usually less intense, and the patient is more manageable.

Lastly, maniacal excitement is to be considered as occurring in the course of other diseases and pathological conditions, coming chiefly under the head of the "Dementing Psychoses," such as senile decay of the brain, paralysis, alcoholism, puerperal affections, hebephremia, paranoia, epilepsy, and in general paresis. It also occurs in idiocy and imbecility. The mental exaltation that accompanies these conditions usually takes on the form of either sub-acute or acute mania. The diagnostic feature in all these diseases. must depend entirely upon the history of the individual case.

In mental exaltation accompanying senile decay of the brain, we obtain a history that the patient has passed the age of sixty, and there is always present a certain amount of dementia or mental enfeeblement. The condition is known as senile mania. In paralysis we get a history of apoplexy. The condition is known as post-apoplectic insanity. In alcoholism, a history of debauch or of chronic alcoholic poisoning is obtained, resulting in alcoholic insanity. In puerperal affections we have a history that the exaltation. followed after parturition or during lactation. It may be of infective origin, but more often is implanted upon a constitution predisposed to insanity on account of an unstable nervous organization. In hebephremia, may be, the condition

manifests itself about the time of the adolescent period. The exaltation in cases of epilepsy may occur prior, during, or after an attack of epilepsy. It may take on the transitory, simple, or acute form. The patient may or may not present delusions, illusions, and hallucinations. In idiocy or imbecility upon which is implanted a condition of mania, it is only necessary to remember and take into consideration the constitutional inferiority.

A case of paranoia usually passes through the periods of invasion and the period of persecution without manifesting a condition of exaltation. Having passed through these evolutionary periods, he enters upon the transition stage, or the period of exaltation and ambition. Ideas of grandeur, pride, power, and wealth are superadded to the existing ideas of persecution. This latter condition is known by some authors as the "monomania of pride and grandeur."

The most important of this latter group of diseases for different diagnosis is that of general paresis. In this affection it is necessary to study both the intellectual and moral as well as the physical symptoms. The disease begins very gradually, but the symptoms are usually unobserved by the friends until questioned about their past history, when they will recall that the patient has been acting strangely for a year or two; that he has been extravagant in many directions, and has had exalted ideas. The patient has probably led a dissipated life and disposed of his savings. The exception to this rule is when the disease begins following an epileptiform seizure or a congestive attack. The mental symptoms of the first stage are mental exaltation, with a degree of motor excitement resembling mania. Delusions of grandeur are frequently present. They take the form of extravagant ideas of self-importance, strength, or great wealth. These symptoms become exaggerated in the second stage. The most prominent physical symptom is the character of the speech, which is of a hesitating nature. In some it is of a drawling, sing-song nature. There is tremor of the tongue and lips; handwriting betrays tremor and failing memory. The reflexes are variable; they may be exagger

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